Thoracic Disc Syndrome: Difference between revisions

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<div class="editorbox"> '''Original Editor '''- '''Original Editor '''- [[User:Sarah Harnie|Sarah Harnie]]


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Sarah Harnie -&nbsp;
 
Lead Editors - Bouzarpour Faryân - Amir Adam - Evelynn Van Hautegem - Alynn De Maeyer
 
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== Search strategy  ==
 
<br>We searched the website of the central library of the university (VUB) and used search engines such as: google scholar, PubMed, Web of Science, Science direct to use. We also used ResearchGate to find scientific articles. Used keywords: “thoracic disc syndrome”, “thoracic disc herniation”,”thoracic disc prolaps” whether or not combined with “description”, “symptoms”, “treatment”, “diagnosis”, “examination”, “physical therapy” <br>We only used articles of which the full text were available using the university platform. <br><br>


== Definition/Description  ==
== Definition/Description  ==
[[File:Sam-burriss-zHSX9o2 B7Y-unsplash.jpg|right|frameless]]
Symptomatic thoracic discogenic pain syndrome (TDPS) is a rare phenomenon making it challenging to diagnose. The rarity of TDPS is attributed to the particular orientation, structure, and function of the thoracic spine in the vertebral column.
* The lordotic nature of the cervical and lumbar spine allows the imaginary line of gravity to run through, allowing them to bear most of the weight of the of the axial skeleton as compared to the thoracic and sacral spine.
* Consequently, they are subject to a higher percentage of degenerated discs and subsequent discogenic pain syndrome.
The majority of the thoracic disc herniation is asymptomatic, or the patient presents with nonspecific symptoms like chest wall pain, epigastric pain, upper extremity pain, and sometimes, a pain in the groin or the lower extremity.
* While the rare nature, coupled with the atypical presentation, may lead to delay in diagnosis.
* Treatment of thoracic discogenic pain syndrome is conservative but sometimes surgical. Surgical interventions, with surgical intervention associated with many complications<ref name=":3" />.


The term ‘thoracic syndrome’ refers to all pathological clinical manifestations due to functional (physiopathological) disturbances and degenerative changes of the thoracic motion segments.<ref name="1">Juergen Kraemer, 2009, Intervertebral Disk Diseases: Causes, Diagnosis, Treatment and Prophylaxis , Thieme , Stuttgart, 375p. (LoE 5)</ref><br>Thoracic disc disease accounts for only 2% of all cases of disc disease and tends to be less serious than disc disease elsewhere in the spine.<ref name="1" /><br>Symptomatic degenerative disc disease is much less common in the thoracic spine than in the cervical and lumbar regions because very little motion is associated with the thoracic spine compared to the neck and low back.<ref name="1" />,<ref name="2">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.</ref><br>It most often affects the lower thoracic spine, between T9 and T12, because of the greater mobility of these vertebrae.<ref name="3">http://www.mdguidelines.com/degeneration-thoracic-or-thoracolumbar-intervertebral-disc</ref><br>Thoracic disc is most seen in the third to fifth decades, and is equally seen in men and women. <br>The herniation of the thoracic disc is relatively uncommon.It is estimated that only 4-5% of all disc herniations take place in the thoracic spine. Even though, it causes a significant problem in health care, because it can often be misdiagnosed and can cause severe morbidity such as irreversible lower extremity weakness ranging in severity from difficulty walking to complete paraplegia. In the study of M. Scott Linscott, was the duration of the symptoms mostly described chronic (lasting longer than 12 weeks) 69% of the cases, 26% of the patients studied had the symptoms for less than 6 weeks (acute) and 5&nbsp;% of the patients had the duration of the symptoms lasting from 6-12 weeks (sub-acute). (18)<br><br>
== Pathophysiology  ==
[[Thoracic Anatomy|Thoracic]] discogenic pain syndrome may be a radicular or myelopathic pain.
* The radicular pain is mostly secondary to posterolateral herniations that compress spinal nerves as they exit through the intervertebral foramen. Radicular pain will usually radiate towards the dermatome of the nerve roots innervated by the exiting nerve.
* Myelopathic pain is seen in central herniations. The herniated disc compresses the spinal cord, leading to sensory and/or motor problems in the corresponding compressed area and below. This is particularly more severe in the thoracic spinal cord since the spinal canal in this region is smaller compared to the cervical and lumbar region. Hence, a slight compression will lead to symptoms<ref name=":3" />.  


== Clinically Relevant Anatomy<br>  ==
== Etiology  ==
Intervertebral disc degeneration primarily causes thoracic discogenic pain syndrome.


Clinically relevant for this condition are the thoracic spine (T1-T12) and the intervertebral discs between the vertebrae. The thoracic spine, starts from the first thoracic vertebrae just under the last cervical vertebrae and extends down about five inches past the angulus inferior of the shoulder blades. At this point the thoracic spine connects with the lumbar spine. In contrast to the lumbar and cervical spine, has the thoracic spine a convex curve. <br>The thoracic spine consist of 12 thoracic vertebrae. The vertebrae are smaller than the lumbar vertebrae and larger and thicker than the cervical vertebrae. The function of these vertebrae is to provide stability. It’s very important to provide protection for vital organs and to hold the body upright. Also the ribs which connect to the thoracic vertebrae by planar joints have a protective function for the organs. Because of the ribs there is a limited flexibility in this region. <br>These discs act like shock absorbers for the spine as it moves. Each disc is made up of an annulus fibrosus and a gel-like inner substance, the nucleus pulposus. Together, the vertebrae and the discs provide the spinal canal to house the spinal cord and spinal nerves. thoracic spine and thoracic vertebrae <br>Because the thoracic vertebrae are stabilized by the thoracic cage it reduces mechanical stress on the intervertebral discs of this region.&nbsp;<ref name="13">Teraguchi M, et all. Metabolic Syndrome Components are Associated with Inervertebral Disc Degeneration: The Wakayama Spine Study. PLoS ONE. 2016;11(2)</ref><br>As the thoracic spine has a shape of kyphosis, the biomechanical characteristics are different when we compare it to the other parts of the human spine. Because of this kyphosis we can see the following differences: the mobility is reduced and the compressing load bearing capacity is increased.<ref name="14">Justin G. R. Fletcher et.al; CT morphometry of adult thoracic intervertebral discs; European Spine Journal; 2015; 24: 2321-2329; LoE: 5</ref>&nbsp;<br>The morphology of the intervertebral disc at the thoracic levels of the spine is different according to one’s age, sex and activity levels. In the study of Justin G. R. Fletcher et.al they conclude that all dimensions (anterior disc height, posterior disc height, anteroposterior dis dimension and transverse disc dimension) of the thoracic disc were greater in men than in women, except the middle disc height. The researchers explain this difference with a scaling effect because the differences in disc and vertebral body heights (6-9%) were proportionally similar to their mean difference in stature (7%). The lower thoracic spine has a larger range of flexion and extension, that is also why the disc height is greater in the more caudal discs of the thoracic spine. This theory also explains why the researchers have found an increased disc height at T2-T3, the segment close to the cervical spine, which is more mobile.Anteroposterior and transverse dimensions of the thoracic intervertebral discs increase caudally because these discs need to support a greater compressive load. The greater axial cross-sectional area reduces compressive stress in these discs.<ref name="14" /><br>Hurxthal et.al reported in a study that anteroir disc height reduces with advancing age. This finding suggests that there is a smaller range of flexion and extension in the thoracic spine in older individuals, and that greater compressive loads are transmitted through the articular facet joints. These factors also result in concomitant postural changes of the thoracic spine. <br>Because older individuals show in general a greater kyphosis of the thoracic spine, the anterior part of the disc has to bear a greater compressive load. This factor also contributes to a reduced disc height because these discs under higher compression will contain reduced levels of water and proteoglycan.<ref name="14" /><br>With advanced age, the metabolism of the discs become impaired, the content of proteoglycan falls and the matrix metalloproteases increase which will cause the degeneration of the matrix and reduced disc height.<ref name="14" />
Thoracic disc lesions are primarily degenerative of nature and affect mostly the lower part of the thoracic spine.&nbsp;Three quarters of incidence occurs below T8, with T11-T12 being most common. 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>


<br>
== Epidemiology ==
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.
[[File:MRI HTML.jpg|right|frameless]]
Thoracic disc herniation is rare and usually asymptomatic. 


<br>
Often found incidentally with MRI. 


<br>
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.<ref name=":3" />
About 80% of patients usually present with problems in the third or fourth decades of life. 


== Epidemiology/Etiology<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">Juergen Kraemer, 2009, Intervertebral Disk Diseases: Causes, Diagnosis, Treatment and Prophylaxis , Thieme , Stuttgart, 375p. </ref>  


=== Characteristics/Clinical Presentation ===
* The majority of the thoracic disc herniation are asymptomatic and are discovered incidentally with an [[MRI Scans|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.


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.


Thoracic disc herniation is a rare event. Of all the herniated discs, less than 1% occur in the thoracic region.
The pain may be:  
<ref name="24">Arce C.A, et all. Thoracic disc herniation. Surg Neurol. 1985;23:356-61 LoE 3A</ref><ref name="25">Ozturk C, et all. Far lateral thoracic disc herniation presenting with flank pain. The Spine Journal. 2006;6:201-203 LoE 3B</ref>
* unilateral or bilateral depending on the location and how significant the herniation is.
&nbsp;According to another study by M. Scott Linscott, 4-5% of all disc herniations happen in the thoracic region.
* intermittent and aggravated by coughing and straining.  
<ref name="18">M. Scott Linscott et.al; Thoracic Intervertebral Disk Herniation: A commonly missed diagnosis; Journal of emergency medicine; vol 32; No. 3; pp. 235-238, 2007 LoE: 2B</ref>
* In rare cases, radiation to the groin, flank, and even the lower extremities<ref name=":3" />.
&nbsp;From the difference between these two studies, we can also conclude that further research is needed to define the prevalence and risk factors of thoracic disc herniations.<br>The thoracic spine is relatively immobile because of the rib cage which reduces the stress on the annulus and lessen the ratio of herniation in this area. In most cases a herniation would result in myelopathy. This because of the small diameter of the thoracic spinal canal.
In upper thoracic and lateral disc herniations
<ref name="23" />
* Radicular pain is more common and often reported in combination with some amount of axial pain.  
&nbsp;The peak age for thoracic disc herniation is 40-50 years, more frequently in men (Arseni &amp; Nash 1960).
* Sensory changes (e.g. parenthesias, dysesthesia) below the level of the lesion.  
<ref name="22">Wilke A, et all. Thoracic disc herniation: a diagnostic challenge. Manual Therapy. 2005;5(3):181-184 LoE: 3B</ref>
* Other symptoms include bladder and bowel dysfunction (15-20% of patients), hyperreflexia and gait impairment.<ref name="p1" /><ref name=":0">Vanichkachorn JS, Vaccaro AR. [https://journals.lww.com/jaaos/Fulltext/2000/05000/Thoracic_Disk_Disease__Diagnosis_and_Treatment.3.aspx Thoracic disk disease: diagnosis and treatment]. JAAOS-Journal of the American Academy of Orthopaedic Surgeons. 2000 May 1;8(3):159-69.</ref>
More than 70% of the thoracic disc herniations are asymptomatic.&nbsp;
[[Red Flags in Spinal Conditions|Red flags]] one should be aware of are:
<ref name="25">Ozturk C, et all. Far lateral thoracic disc herniation presenting with flank pain. The Spine Journal. 2006;6:201-203 LoE 3B</ref>
* Myelopathy (injury to the spinal cord due to severe compression)
<br>Thoracic disc lesions are primarily degenerative and affects mostly the lower part of the thoracic spine.
* Gait disturbance
<ref name="22" />
* Paralysis
&nbsp;<br>There is a debate about the etiology of this condition, as researchers are uncertain about the role of injury in patients with thoracic disc herniation. Reports say, only 25% of all cases of thoracic disc herniation is caused by trauma. According to M. Scott Linscott et. al, injury probably plays a bigger role, as they have found that 49% of patients in their study have documented a specific traumatic event as the initiator of their symptoms.&nbsp;
* Cardiovascular disturbances
<ref name="18" />
* History of:Cancer; Trauma; Tumor; Infection; Constitutional symptoms (feeling ill); Weight loss; Laboratory abnormalities
<br>What they also have found in this study was that 26% of their patients had multiple-level herniations and 12% of the patients had disk protrusions at non-contiguous levels.
<ref name="18" />
 
 
The development of thoracic disc degeneration is not well defined. . A history of trauma may be present in younger individuals who develop thoracic pain. Those with chronic spinal cord or nerve root compression frequently have prolonged symptoms, although MRI studies on asymptomatic people note that asymptomatic disc herniations are seen in up to one-third of these asymptomatic people.&nbsp;<ref name="3" /><br>Symptomatic thoracic disc degeneration may develop if affected discs have herniated or become displaced. In disc herniation, symptoms may occur when the annulus fibrosus of the degenerated disc slips from its normal position between the vertebrae, or the nucleus pulposus of the disc protrudes through the annulus. Individuals with congenital or developmental deformities of the spine such as scoliosis or kyphosis may be more likely to develop thoracic disc degeneration.&nbsp;<ref name="3" /><br>
 
<br>
 
== Characteristics/Clinical Presentation<br>  ==
 
 
 
Most of the time the thoracic disc disorders are located in the mid back at the thoracolumbar junction (T8-T12).
<ref name="25">Ozturk C, et all. Far lateral thoracic disc herniation presenting with flank pain. The Spine Journal. 2006;6:201-203 LoE 3B</ref>
&nbsp;Mostly these disc disorders do not cause any symptoms because the disc is almost completely without nociceptive structures.&nbsp;
<ref name="25" />
<br>If, nevertheless, symptoms are extant, pain is the most common.
<ref name="21">Linscott M.S, et all. Thoracic intervertebral disk herniation: a commonly missed diagnosis. The Journal of Emergency Medicine. 2007;32(3):235-238 LoE: 3B</ref>
&nbsp;The pain can be located in the upper back or radiated in a dermatomal pattern.
<ref name="21" />
The pain can be exacerbated when sneezing or coughing.
<ref name="26">Malanga G, et all. Thoracic Discogenic Pain Syndrome. [http://emedicine.medscape.com/article/96284-clinical#b1] recieved 1 may 2016</ref>
<br>If the pain is purely discogenic, it will be dull and localized to the thoracic spine. Sometimes an upper thoracic disc herniation may cause cervical pain and lower thoracic disc herniations lower back pain.<br>The pain can also be referred to the retrosternal, retrogastric or inguinal areas which can cause misdiagnoses such as myocardial infarction, cholecystitis or nephrolithiasis.
<ref name="23" />
<br>When annular tears are present they can refer pain based on the anatomic location of the tear. The referred pain of anterior tear can be located in the ribs, chest wall, sternum and visceral structures.
<ref name="22" /><ref name="25" />
Posterior tears creates local or diffuse back pain and lateral tears can cause radicular pain to visceral of musculoskeletal areas.<br>When a disc protrusion compromises thoracic nerve roots symptoms can be present as described above or it can be a radicular pain. Radicular pain can be intermittend or constant, mostly described as burning, electric or shooting.
<ref name="25" />
<br>Presenting symptoms depend on the size and location of the disc protrusion. A larger protrusion may compress the ganglion of the nerve root fibers, resulting in motor and/or sensory disturbances in the innervation’s area of the root.<br>A central disc protrusion usually causes upper back pain and/or myelopathy. Because of the limited space around the spinal cord in this region, pressure can be put on the spinal cord and affect the related nerve fuction. In severe cases, this can lead to paralysis from the waist down.
<ref name="19">Whitmore R.G, et all. A patient with thoracic intradural disc herniation. Journal of Clinical Neuroscience 18. 2011:1730-1732 LoE:3B</ref>
<br>A lateral disc herniation can impinge the exiting nerve root and cause radiating chest wall or abdominal pain.<br>A centro-lateral disc herniation can have a combination of symptoms of upper back pain, radiating pain or myelopathy. <br>Other symptoms are sensory disturbances, presenting in 25% of patients with thoracic discogenic pain syndrome. The most common sensory disturbance is numbness. Also paresthesias in dermatomal distributions and dysasthesias can be reported.
<ref name="19" /><ref name="20">20 Deitch K, et all. T2-3 Thoracic disc herniation with myelopathy. The journal of Emergency Medicine.2009;36(2):138-140 LoE 3B</ref><ref name="21">Linscott M.S, et all. Thoracic intervertebral disk herniation: a commonly missed diagnosis. The Journal of Emergency Medicine. 2007;32(3):235-238 LoE: 3B</ref><ref name="25" />
<br>Weakness in the abdominal and intercostal muscles aren’t early presenting symptoms. Weakness of the lower extremities when compression and myelopathy are present are more likely.
<ref name="21" /><ref name="23" /><ref name="25" />
<br>Other rather uncommon symptoms are bladder symptoms such as incontinence.
<ref name="20" /><ref name="21" /><ref name="22" /><ref name="25" />
<br>Most of the thoracic disc herniations are asymptomatic. The most common complaint of these patients is radicular chest pain.
<ref name="15">Vijay Singh, MD et.al; An update of the appraisal of the accuracy of thoracic discography as a diagnostic test for chronic spinal pain; Pain Physician 2012; 15: E757- E776 ; LoE: 2A</ref>
 
 
<br>
 
== Differential Diagnosis  ==
== Differential Diagnosis  ==


Thoracic disc herniations are commonly misdiagnosed as cardiac disorders, abdominal problems, gastrointestinal, neoplastic and demyelinating diseases, tumours, ankylosing spondylitis and intercostal neuralgia.<ref name="21" /><ref name="22" />(<ref name="25" />
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.
- Cervical disk injuries: A cervical herniated disc is diagnosed when the inner core of a disc in the neck herniates, or leaks out of the disc, and presses on an adjacent nerve root.<ref name="39">Torg J. Epidemiology, pathomechanics, and prevention of athletic injuries to the cervical spine. The Cervical Spine. 1989. 442-463.(LoE:5)</ref>
* Important that the patient is examined thoroughly to rule out all other causes for symptoms.<ref name="p1" /><ref name=":0" /><ref name=":3" />
 
Rule out conditions such as
- Cervical Radiculopathy: Radiculopathy refers to a set of conditions in which one or more nerves are affected and do not work properly (a neuropathy). The location of the injury is at the level of the nerve root.<ref name="38">Bogduk N, Twomey LT. Clinical Anatomy of the Lumbar Spine. 2nd ed. Edinburgh, UK: Churchill Livingstone Inc; 1991.( LoE:5)</ref>
* [[Diabetes]] and shingles
 
* Other mechanical issues such as oblique muscle pain, [[Rib stress fracture in rowers|rib fracture]], [[fracture]] of the [[Facet Joint Syndrome|facet joints]] and clavicle
- Lumbosacral disc injuries: Collective name for injuries of lumbosacral discs.<ref name="27">27 Kalichman L, Hunter DJ. Diagnosis and conservative management of degenerative lumbar spondylolisthesis. Eur Spine J. 2008 Mar. 17(3):327-35. . LoE: 1B</ref>,<ref name="28">Metz LN, Deviren V. Low-grade spondylolisthesis. Neurosurg Clin N Am. 2007 Apr. 18(2):237-48. LoE:2A</ref>,<ref name="29">29 Lonstein JE. Spondylolisthesis in children. Cause, natural history, and management. Spine. 1999 Dec 15. 24(24):2640-8. LoE: 1B</ref>,<ref name="30">Esses SI ed. Spondylolisthesis. Textbook of Spinal Disorders. Philadelphia, Pa: Lippincott Williams &amp; Wilkins; 1995. 203-13.( LoE:5)</ref>,<ref name="31">Guanciale AF, Dillin WH, Watkins RG. Back pain in children and adolescents. In. Herkowitz HN, Rothman RH, Simeone FA, Balderston RA, eds. The Spine. 4th ed. Philadelphia, Pa: WB Saunders Co; 1999. Vol 1: 197-203, 835-85. LoE:3</ref>,<ref name="32">Sinaki M, Mokri B. Low back pain and disorders of the lumbar spine. Braddom RL, ed. Physical Medicine and Rehabilitation. Philadelphia, Pa: WB Saunders Co; 1996. 831-3, 844( LoE:5)</ref>)
* Malignancies, like neurofibroma
* Herpes zoster (can cause segmentally radiating pain with postherpetic [[Neuropathic Pain|neuralgia]])
* Costotransverse joint syndrome due to inflammatory changes or arthrosis
* Infections, tumors and dilated arteries of the chest wall
* [[Referred Pain|Referred pain]] from the organs (zones of Head)
* [[Tietzes|Tietze syndrome]]
* [[Scheuermann's Kyphosis|Scheuermann kyphosis]]
Pain referred around the chest wall tends to be costovertebral in origin.<ref name=":4">Magee, D. J. (2008). Orthopedic physical assessment. St. Louis, Mo: Saunders Elsevier. Print</ref>


- Lumbosacral Discogenic Pain Syndrome:Discogenic pain is pain originating from a damaged vertebral disc, particularly due todegenerative disc disease. However, not all degenerated discs cause pain. Disc degeneration occurs naturally with age.<ref name="37">37 Hicks GE, Morone N, Weiner DK. Degenerative lumbar disc and facet disease in older adults: prevalence and clinical correlates. Spine (Phila Pa 1976). 2009 May 20. 34(12):1301-6 LoE: 2B</ref>
== Physical examination  ==
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)  - [[Adsons Test|Adson’s test]]  - [[Costoclavicular (Military) Brace Test|Costoclavicular maneuver]]  - Hyperabduction (EAST) test  - [[Roos Stress Test|Roos test]]  - [[Slump Test|Slump test]]
* Reflexes and cutaneous distribution (sitting)  - [[Reflexes|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 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
After any assessment, the patient should be warned of the possibility of exacerbation of symptoms as a result of assessment.<ref name=":4" />


- Lumbosacral Radiculopathy:Lumbosacral radiculopathy, like other forms of radiculopathy, results from nerve root impingement and/or inflammation that has progressed enough to cause neurologic symptoms in the areas that are supplied by the affected nerve root <ref name="34">Bull RC, ed. Dance injuries. Bull's Handbook of Sports Injuries. Baltimore, Md: McGraw-Hill; 1999. 627-8.(LoE:5)</ref>,<ref name="35">Braddom RL, ed. Physical Medicine and Rehabilitation. Philadelphia, Pa: WB Saunders Co; 1996. 844-6.(LoE:5)</ref>,<ref name="36">Birnbaum JS. The Musculoskeletal Manual. 2nd ed. Orlando, Fla: Greene &amp; Stratton; 1986. 135. (LoE:5)</ref>)
'''Elaboration on some testing'''


- Lumbosacral Spondylolisthesis:Spondylolisthesis is defined as forward translation of a vertebral body with respect to the vertebra below <ref name="27" />,<ref name="28" /><ref name="29" />,<ref name="30" />,<ref name="31" />,<ref name="32" />)<br>-Lumbosacral Spondylosis:Lumbar spondylosis, as shown in the image below, describes bony overgrowths (osteophytes), predominantly those at the anterior, lateral, and, less commonly, posterior aspects of the superior and inferior margins of vertebral centra (bodies). This dynamic process increases with, and is perhaps an inevitable concomitant, of age.<ref name="33">Brooks BK, Southam SL, Mlady GW, Logan J, Rosett M. Lumbar spine spondylolysis in the adult population: using computed tomography to evaluate the possibility of adult onset lumbar spondylosis as a cause of back pain. Skeletal Radiol. 2010 Jul. 39 (7):669-73. LoE:1B</ref><br><br>
Assess passive movements of the thoracic spine and the end feel:<ref name=":4" />


== Diagnostic Procedures  ==
• Forward flexion (tissue stretch)


The use of CT in combination with myelography and MRI greatly increased the ability to accurately visualize thoracic spine disorders.&nbsp;<ref name="2" /><br>A myelogram usually indicates the level of the lesion with certainty, although, special projections may be needed. <ref name="9">Ransohoff J, Spencer E, Siew F, Gage L. Case reports and technical notes. Trans-thoracic removal of thoracic disc. J Neurosurg 1969; 31:459-461 (level C)</ref><br>Today, MRI is the imaging method of choice in the investigation of the thoracic spinal canal. <ref name="10">Wallace JC, Fong TC, Macrae ME. Calcified herniatopns of the thoracic disdk: role of magnetic resonance imaging and computed tomography in surgical planning. Can Assoc Radiol J. 1992; 43(1):52-54 (level C)</ref><br>Since a past few decades, thoracic discography is being used as a safe procedure by skilled clinicians. The purpose of this diagnostic mechanism is to be able to precisely identify the disc level(s) which are the source of chronic thoracic spinal pain. &nbsp;<br>There is a main diagnostic criteria for thoracic discogenic pain described by The Task Force on Taxonomy of Classification of Chronic Pain in 1994: the patient’s pain must be originating from an intervertebral disc by provocation discography of the disc which is believed to be affected. This provocation needs to reproduce the patient’s accustomed pain, and at least 2 adjacent intervertebral discs also need to be provoked with no result of reproducing the patient’s pain. The pain also can not be originating from another source innervated by the same segments that innervate the disc believed to be affected.&nbsp;<br>The Task Force also says, that thoracic discography itself is insufficient to diagnose discogenic pain because of the number of false-positive responses. This is the reason why the evidence for supporting the use of discography to diagnose thoracic discogenic pain is limited. <br><br>
• Extension (tissue stretch)


==  ==
• Side flexion, left and right (tissue stretch)


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.
• Rotation, left and right (tissue stretch)
<ref name="11">E Bruckner 'Benign thoracic pain' syndrome: role of magnetic resonance imaging in the detection and localization of thoracic disc disease. Journal of the Royal Society of Medicine; 1989 Volume 82, 81-83. (level 4)</ref>
<br>MRI is preferred because it is non-invasive, has a high soft-tissue resolution, and has multiplanar imaging capabilities.MRI is superior to CT to demonstrate degenerative changes, disc protrusion and nerve root compression. Also intra- and extradural tumours can easily be seen on MRI.
<ref name="25" />


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


<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.


== Examination  ==
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">Shirzadi A, Drazin D, Jeswani S, Lovely L, Liu J. [https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3638501/ Atypical presentation of thoracic disc herniation: case series and review of the literature]. Case reports in orthopedics. 2013;2013.</ref><ref name="p0">Deitch K, Chudnofsky C, Young M. [https://www.ncbi.nlm.nih.gov/pubmed/17976778 T2–3 Thoracic Disc Herniation with Myelopathy]. The Journal of emergency medicine. 2009 Feb 1;36(2):138-40. </ref> />


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 on T2-weighted MRI. Disc degeneration can be detected by a reduced signal intensity due to loss of water from the nucleus pulposus. [11]
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>
== Outcome measures  ==
* [[Occiput to Wall Distance OWD|Occiput to Wall]] Distance
* [[Visual Analogue Scale|VAS-pain scale]]
* [[Pain Catastrophizing Scale]]
* [[Fear Avoidance Belief Questionnaire|Fear-avoidance Beliefs Questionnaire]]
* [[Patient Specific Functional Scale]]
* [[Fingertips to Floor Distance - Special Test|Fingertips to Floor]]


A completer overview of a manual examination performed by a physiotherapist can be viewed ‘here” (LINK http://www.physio-pedia.com/Thoracic_Examination)<br>
=== 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. 
== Medical Management<br>  ==
* Conservative management includes rest, [[Pain Medications|anti-inflammatory drugs]], and physical therapy.
 
* Drugs like Pregabalin have been reported to be useful for the numbness and radicular pain.
Most patients with symptomatic thoracic disc disease will respond favourably to non-operative management. Surgery is indicated for the rare patient with an acute thoracic disc herniation with progressive neurologic deficit (i.e., signs or symptoms of thoracic spinal cord myelopathy). [2] Remarkable recovery of neurological functions is observed after surgical decompression of the spinal cord.(36) (level of evidence 4)
* Selective spinal root or intercostal nerve blockade and [[Therapeutic Corticosteroid Injection|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.<ref name=":3" />
Surgical Approaches for Thoracic Disc Herniation (TDH)(46)(13)<br>Anterior<br>• Transthoracic<br> Trans-sternal<br> Transpleural (thoracotomy)<br> Retropleural<br> With rib resection<br> Between ribs (using tubular retractor)<br>• Thoracoscopy<br>Posterolateral<br>• Lateral extracavitary<br>• Costotransversectomy<br>• Transpedicular<br>• Transforaminal<br>• Transfacet pedicle sparing<br>• Facetectomy<br> Unilateral<br> Bilateral
 
The anterolateral approach is more suited in case of central herniated discs, while the posterolateral approach is best for paracentral or lateral herniated discs. Minimally invasive thoracoscopic techniques were introduced to reduce morbidities related to thoracotomy, like persisting pain 4 to 5 years post-thoracotomy, with satisfactory long-term outcomes. For midline giant TDH however, open thoracotomy is recommended rather than thoracoscopy. To prevent instability, intervertebral fusion is indicated in patients undergoing wide resection of structures during discectomy. (46) (level of evidence 2A)<br><br>  


== Physical Therapy Management  ==
== Physical Therapy Management  ==
[[File:Massage image.jpg|right|frameless]]
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="p0" /><ref name=":7">Manchikanti L, Hirsch JA. [https://www.ncbi.nlm.nih.gov/pubmed/25982996 Clinical management of radicular pain.] Expert review of neurotherapeutics. 2015 Jun 3;15(6):681-93.</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. [https://www.ncbi.nlm.nih.gov/pubmed/25607736 Running exercise alleviates pain and promotes cell proliferation in a rat model of intervertebral disc degeneration.] International journal of molecular sciences. 2015 Jan;16(1):2130-44.</ref><ref>Steele J, Bruce-Low S, Smith D, Osborne N, Thorkeldsen A. [https://www.ncbi.nlm.nih.gov/pubmed/26409630 Can specific loading through exercise impart healing or regeneration of the intervertebral disc?.] The Spine Journal. 2015 Oct 1;15(10):2117-21.</ref> Most patients (80%) with a prolapsed intervertebral disc respond in 4-6 weeks to conservative therapy.<ref>Hofstee DJ, Gijtenbeek JM, Hoogland PH, van Houwelingen HC, Kloet A, Lötters F, Tans JT. [https://www.ncbi.nlm.nih.gov/pubmed/11797655 Westeinde sciatica trial: randomized controlled study of bed rest and physiotherapy for acute sciatica.] Journal of Neurosurgery: Spine. 2002 Jan 1;96(1):45-9.</ref><ref>Weber H, Holme I, Amlie E. [https://www.ncbi.nlm.nih.gov/pubmed/8235813 The natural course of acute sciatica with nerve root symptoms in a double-blind placebo-controlled trial evaluating the effect of piroxicam]. Spine. 1993 Sep;18(11):1433-8..</ref> 


Click “here” for a complete “Evidence-Informed Back Education Program”&nbsp;: (http://www.physio-pedia.com/Back_Education_Program)
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" /> 


<br>
Some ideas from Physiopedia for physical therapy treatment:
 
* [[Exercise in Pain Management|Exercise in pain management]]
A Case-study shows us that the therapy of a thoracic disc herniation has to contain hyperextension strengthening exercises, postural training and body-mechanic education. The therapy of thoracic disc herniation is very similar to the therapy of the neck and the low back.(16)(level of evidence 4)
* [https://www.physiospot.com/opinion/my-top-3-thoracic-spine-mobility-exercises/ Top 3 thoracic spine mobility exercises] (Physiospot)
 
* [[Thoracic Manual Techniques and Exercises]]
Parts of the therapy are: <br>Postural training and body-mechanic education: <br>The purpose of the training is to correct and to educate the patient in order to maintain a straight back.(16)(18) An exercise to achieve this is to have the patient straighten his back by standing against a wall or by looking into a mirror and correcting himself.(19)(20) An example for postural training exercise are core exercises (seated barbell twist, the barbell side bench, etc.)(47)
 
Back strengthening exercise:<br>The meaning of this exercise is to strengthen the weakened back muscles (thoracic area). An example of exercise are wall push-ups, back extension<br>(20) (48) (levels of evidence 1A, 5)<br>If the patient does strengthening exercises of the back extensors, he also needs to train the antagonists of the trained muscles otherwise there will be a great loss of postural control. (Agonist = back extensors, antagonist = abdominis muscles) (49)
 
Manual therapists and osteopaths claim that almost all thoracic disc protrusions can be reduced by manipulation in 3 to 5 sessions. [5]<br>If manipulation does not succeed after 3 sessions, the diagnosis should be reconsidered and, if a disc lesion is confirmed, traction can be tried. Traction can also be used for thoracic postural pain syndrome and for lateral recess stenosis in the thorax. Other treatments are sinuvertebral blocks for persistent root pain or for root pain with neurological deficit: surgery, bed rest and prevention of recurrence. [5]
 
Manipulations [5]
 
Indications:<br>All actual and symptomatic thoracic disc protrusions in the absence of contraindications should be manipulated. <br>Contra-indications: <br> -Relative: Absence of actual symptomatic disc displacement<br> Self-reducing disc lesion<br> Monoradicular neurological deficit<br> -Absolute: Signs and/or symptoms of cord compression<br> Patients with bleeding disorders<br> Patients on anticoagulant treatment<br>Techniques:<br>Thoracic manipulations are always performed under strong traction.<br>3 main types of procedure are considered: <br> 1: Extension techniques, in which extension is always present, sometimes combined with rotation.
 
2: Rotation techniques, in which rotation is the only component.<br> 3: High thoracic technique, used only in upper thoracic disc lesions<br>All extension manipulations of the thoracic spine are specific; they are performed only at 2 vertebrae where the disc protrusion lies in between.
 
When manipulations are unsuccessful: <br>It should be accepted that either the diagnosis is wrong or the disc lesion is not suitable for manipulation. <br>When the diagnosis is wrong, one must consider possibilities, like: Facet joint, tumour, muscular lesion, osseous Lesion, ligamentous lesion, visceral disorder. [5]<br>Some cases respond better to oscillations. These consist of gentle high-frequency mobilizations at 2 or 3 vibrations per second. Oscillations should be given for 10-15 minutes daily and are performed as central or as unilateral pressure to the thoracic spine. [12]  
 
Indications: <br>Three groups of indications: <br> - Patients who present with much discomfort but with very minor articular signs on clinical examination. <br> - Patients with acute thoracic lumbago who are in such pain that they cannot put up with normal manipulations. Oscillatory techniques can be used until the pain is reduced to a level at which normal manipulations can be started.<br> - Patients who cannot tolerate the extension or rotation techniques. [11] (level of evidence 3B)
 
<br>
 
<br><br>
 
== Key Evidence  ==
 
• H. Yoshihara, Surgical Treatment for Thoracic Disc Herniation, An Update. Spine 2014;39:E406–E412.<br>• E.M.J. Cornips et al., Thoracic disc herniation and acute myelopathy: clinical presentation, neuroimaging findings, surgical considerations, and outcome. J Neurosurg Spine 14:520–528, 2011<br>• George A Koumantakis et al; Trunk Muscle Stabilization Training Plus General Exercise Versus General Exercise Only: Randomized Controlled Trial of Patients With Recurrent Low Back Pain; PHYS THER. 2005; 85:209-225.<br><br>
 
== Resources <br>  ==
 
1. ↑ 1.0 1.1 1.2 Juergen Kraemer, 2009, Intervertebral Disk Diseases: Causes, Diagnosis, Treatment and Prophylaxis , Thieme , Stuttgart, 375p. <br>2. ↑ 2.0 2.1 2.2 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. <br>3. ↑ 3.0 3.1 3.2 3.3 http://www.mdguidelines.com/degeneration-thoracic-or-thoracolumbar-intervertebral-disc <br>4. ↑ http://www.spineuniverse.com/conditions/degenerative-disc/anatomy-degenerative-disc-disease (level of evidence 5)<br>5. ↑ 5.0 5.1 5.2 5.3 5.4 5.5 5.6 5.7 L. Ombregt, P. Bisschop, H.J. Ter Veer. 2002. A System of Orthopaedic Medicine, second edition. Churchill Livingstone. 1360p. <br>6. ↑ Lyu RK, Chang HS, Tang LM, Chen ST. Thoracic disc herniation mimicking acute lumbar disc disease. Spine. 1999; 24 (4): 416-418 <br>7. ↑ Cyriax J. textbook of orthopaedic medicine, vol 1, diagnosis of soft tissue lesions, 8th edn. Ballière Tindall, London, 1982. (level of evidence 5)<br>8. ↑ J. MCInerney, P. A. Ball. The pathophysiology of thoracic disc disease. Neurosurg. Focus Volume 9 , 2000 (level of evidence 3A)<br>9. ↑ Ransohoff J, Spencer E, Siew F, Gage L. Case reports and technical notes. Trans-thoracic removal of thoracic disc. J Neurosurg 1969; 31:459-461 (level of evidence 4)<br>10. ↑ Wallace JC, Fong TC, Macrae ME. Calcified herniatopns of the thoracic disk: role of magnetic resonance imaging and computed tomography in surgical planning. Can Assoc Radiol J. 1992; 43(1):52-54 (level of evidence 4)<br>11. ↑ 11.0 11.1 F E Bruckner 'Benign thoracic pain' syndrome: role of magnetic resonance imaging in the detection and localization of thoracic disc disease. Journal of the Royal Society of Medicine; 1989 Volume 82, 81-83. (level of evidence 3B)<br>12. ↑ Maitland G, Brewerton D. Vertebral manipulation. Butterworth, London, 1977:7. <br>13. Kiyoshi Otani, Sadaaki Nakai, Yoshikazu Fujimura, Shunichi Manzoku, Keiichi Shibasaki, Surgical treatment of thoracic disc herniation using the anterior using the anterior approach. the journal of bone and joint surgery, 1982<br>14. DS McNally et al, Intervertebral disc structure: observation by a novel use of ultrasound imaging, Ultrasound in Medicine &amp; Biology, Volume 26, Issue 5, June 2000, Pages 751–758 (level of evidence 3A)<br>15. PW Stratford et al, Development and Initial Validation of the Back Pain Functional Scale, The Journal of rheumatology, 2000 (level of evidence 2B)<br>16. Courtney W. Brown et al; The natural history of thoracic disc herniation, Spine Volume 17 - number 6 supplement; 1992 ( 4)<br>17. Feise RJ et al, Functional Rating Index: A New Valid and Reliable Instrument to Measure the Magnitude of Clinical Change in Spinal Conditions, Spine 2001 Mar 1;26(5):596 (level of evidence 2B)<br>18. Deborah Falla et al; Recruitment of the deep cervical flexor muscles during a postural-correction exercise performed in sitting; Manual Therapy 12 (2007) 139–143 ( 2B)<br>19. George A Koumantakis et al; Trunk Muscle Stabilization Training Plus General Exercise Versus General Exercise Only: Randomized Controlled Trial of Patients With Recurrent Low Back Pain; PHYS THER. 2005; 85:209-225. (1B)<br>20. Joshua A. Cleland et al&nbsp;;Examination of a Clinical Prediction Rule to Identify Patients With Neck Pain Likely to Benefit From Thoracic Spine Thrust Manipulation and a General Cervical Range of Motion Exercise: Multi-Center Randomized Clinical Trial; PHYS THER. 2010; 90:1239-1250 (Level of evidence 1A)<br>21. Takuji Matsumoto, Muneharu Ando, Hiromi Hamazaki; Intradural herniation of a thoracic disc presenting as left radicular pain and left drop foot;Interdisciplinary Neurosurgery,Volume 2, Issue 3, September 2015, Pages 129–132 <br>LEVEL OF EVIDENCE 4 <br>22. Charles B. Stillerman, M.D., Thomas C. Chen, M.D., Ph.D., William T. Couldwell, M.D., Ph.D., Wei Zhang, M.D., Ph.D., and Martin H. Weiss, M.D.;Experience in the surgical management of 82 symptomatic herniated thoracic discs and review of the literature; J Nerosurg, 88 (1998), pp. 623–633 <br>LEVEL OF EVIDENCE 1A <br>23. DENNIS G. VOLLMER, M.D., AND NATHAN E. SIMMONS, M.D.; Transthoracic approaches to thoracic disc herniations; Neurosurg Focus 9 (4):E8, 2000<br>LEVEL OF EVIDENCE 5<br>24. Schellhas KP, Pollei SR, Dorwart RH. Thoracic discography. A safe and reliable technique. Spine. 1994 Sep 15. 19(18):2103-9.<br>LEVEL OF EVIDENCE 2b<br>25. http://twinboro.com/body/spine/thoracic/disc/conditions/thoracic-degenerative-disc-disease-nj.html LEVEL OF EVIDENCE 5 <br>26. Wood KB, Garvey TA, Gundry C, et al: Magnetic resonance imaging of the thoracic spine. Evaluation of asymptomatic individuals. J Bone Joint Surg (Am) 77:1631–1638, 1995<br>LEVEL OF EVIDENCE 2b<br>27. RC O’Connor et al, Thoracic radiculopathy, Phys Med Rehabil Clin N Am 13 (2002) 623–644 (level of evidence 2A)<br>28. HZ Wahner et al, Noninvasive bone mineral measurements, Radionuclide Studies in the Evaluation of Trauma—Part II, July 1983, Pages 282–289 (level of evidence 3A)<br>29. NE Epstein et al, Thoracic Spinal Stenosis: Diagnostic and Treatment Challenges, Journal of Spinal Disorders, June 1994 (level of evidence 4)<br>30. MG Karnaze et al, Comparison of MR and CT myelography in imaging the cervical and thoracic spine, American Journal of Roentgenology. 1988 (level of evidence 3B)<br>31. MH Bilsky et al, The Diagnosis and Treatment of Metastatic Spinal Tumor, The Oncologist December 1999 vol. 4 no. 6 459-469 (level of evidence 3A)<br>32. MW Fidler, Surgical treatment of giant cell tumours of the thoracic and lumbar spine: report of nine patients, Eur Spine J, 2001 (level of evidence 4)<br>33. N Sehgal et al, Diagnostic Utility of Facet (Zygapophysial) Joint Injections in Chronic Spinal Pain: A Systematic Review of Evidence, Pain Physician. 2005 (level of evidence 2A)<br>34. Giuseppe Guglielmi, Osteoporosis and Bone Densitometry Measurements, Springer, 2013 pages 51-52 (level of evidence 3A)<br>35. http://neuroscience.uth.tmc.edu/s2/chapter03.html (level of evidence 5)<br>36. E.M.J. Cornips et al., Thoracic disc herniation and acute myelopathy: clinical presentation, neuroimaging findings, surgical considerations, and outcome. J Neurosurg Spine 14:520–528, 2011. (level of evidence 4)<br>37. G. Sheean, The pathophysiology of spasticity. European Journal of Neurology 2002, 9 (Suppl. 1): 3–9. (level of evidence 5)<br>38. H.L. Frankel et al., The value of postural reduction in the initial management of closed injuries of the spine with paraplegia and tetraplegia. Paraplegia. 1969 Nov;7(3):179-92.(level of evidence 4)<br>39. http://www.rehabmeasures.org/Lists/RehabMeasures/PrintView.aspx?ID=1033(level of evidence 5)<br>40. http://www.medicalcriteria.com/site/en/criteria/64-neurology/238-neuromrc.html(level of evidence 5)<br>41. http://www.erasmusmc.nl/cs-fysiotherapie/beeld/4887961/h.emnsa(level of evidence 5)<br>42. http://www.rehabmeasures.org/Lists/RehabMeasures/PrintView.aspx?ID=902 (level of evidence 5)<br>43. http://www.ncbi.nlm.nih.gov/books/NBK397/(level of evidence 5)<br>44. http://www.ncbi.nlm.nih.gov/books/NBK396/(level of evidence 5)<br>45. http://www.ipphysio.com/documents/Pelvic%20Floor%20Grading%20Systems.pdf(level of evidence 5)<br>46. H. Yoshihara, Surgical Treatment for Thoracic Disc Herniation, An Update. Spine 2014;39:E406–E412.(level of evidence 2A)<br>47. http://www.bodybuilding.com/fun/beginner-core-training-guide.htm (level of evidence 5)<br>48. http://www.bodybuilding.com/fun/beginner-back-training-guide.htm (level of evidence 5)<br>49. Kollmitzer J, Ebenbichler GR, Sabo A, Kerschan K, Bochdansky T. Effects of back extensor strength training versus balance training on postural control. Med Sci Sports Exerc. 2000 Oct;32(10):1770-6..(level of evidence1B )<br>
 
• http://www.spineuniverse.com/sites/default/files/imagecache/gallery-large/wysiwyg_imageupload/3998/2015/04/02/DDD_labeled.jpg (foto disc deseases)<br>• http://keckmedicine.adam.com/graphics/images/en/19469.jpg (disc anatomy Adam)<br>• Video link: explanation thoracic herniation disc&nbsp;: http://www.spine-health.com/video/thoracic-herniated-disc-video&nbsp;<br>
 
<br>


== Case Studies  ==
== Case Studies  ==
 
# [https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5131583/ Unusual chest wall pain caused by thoracic disc herniation in a professional baseball pitcher]
add links to case studies here (case studies should be added on new pages using the &lt;a href="Template:Case Study"&gt;case study template&lt;/a&gt;)<br>
# [https://www.ncbi.nlm.nih.gov/pubmed/26156777?log$=activity Histologically proven acute paediatric thoracic disc herniation causing paraparesis]
# [https://www.ncbi.nlm.nih.gov/pubmed/19404165 Acute chest pain in a top soccer player due to thoracic disc herniation]


== Clinical Bottom Line  ==
== Clinical Bottom Line  ==
* [[File:Thoracic manip.JPG|right|frameless]]Thoracic discogenic pain syndrome (TDPS) is rare making it challenging for the healthcare team to diagnose and treat the condition.
* The rarity of TDPS is attributed to the particular orientation, structure, and function of the thoracic spine in the vertebral column.
* Despite this rarity, physiotherapists, physician assistants, and physicians should be familiar with its diagnosis and treatment and work as an interprofessional team to provide treatment<ref name=":3" />
* 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.<ref name="p0" /> <ref name=":7" /><br>


Thoracic pain can have different causes, including red flags (vertebral fractures, tumoral processes, visceral problems), making a differential diagnosis crucial. TDH is mostly asymptomatic and when symptomatic, possible clinical signs of myelopathy are mostly delayed and preceded by thoracic back pain, similarly to the pathophysiological process in lumbar and cervical radiculopathy. T2-weighted MRI is the diagnostic imaging technique of choice. Neurological examination of the patient should be carried out to detect clinical signs of cord compression, as motor deficit is an urgent indication for surgical decompression. Some thoracic manipulations seem to reposition protruded discs, but myelopathy is an absolute contraindication to manual therapy. Postural and stability training seems indicated in cases of disc degeneration.
== References ==
 
<references />
<br>
[[Category:Thoracic Spine]]
 
[[Category:Musculoskeletal/Orthopaedics‏‎]]
== Recent Related Research ==
[[Category:Primary Contact]]
[[Category:Syndromes]]
[[Category:Conditions]] 
[[Category:Thoracic Spine - Conditions]]

Latest revision as of 12:30, 17 October 2023

Original Editor - Original Editor - Sarah Harnie Top Contributors - Sarah Harnie, Maarten Wuijts, Arno Vrambout, Lucinda hampton, Kim Jackson, Marleen Moll, Rachael Lowe, Claire Knott, 127.0.0.1, Bouzarpour Faryân, Abbey Wright, Admin, Evan Thomas and WikiSysop

Definition/Description[edit | edit source]

Sam-burriss-zHSX9o2 B7Y-unsplash.jpg

Symptomatic thoracic discogenic pain syndrome (TDPS) is a rare phenomenon making it challenging to diagnose. The rarity of TDPS is attributed to the particular orientation, structure, and function of the thoracic spine in the vertebral column.

  • The lordotic nature of the cervical and lumbar spine allows the imaginary line of gravity to run through, allowing them to bear most of the weight of the of the axial skeleton as compared to the thoracic and sacral spine.
  • Consequently, they are subject to a higher percentage of degenerated discs and subsequent discogenic pain syndrome.

The majority of the thoracic disc herniation is asymptomatic, or the patient presents with nonspecific symptoms like chest wall pain, epigastric pain, upper extremity pain, and sometimes, a pain in the groin or the lower extremity.

  • While the rare nature, coupled with the atypical presentation, may lead to delay in diagnosis.
  • Treatment of thoracic discogenic pain syndrome is conservative but sometimes surgical. Surgical interventions, with surgical intervention associated with many complications[1].

Pathophysiology[edit | edit source]

Thoracic discogenic pain syndrome may be a radicular or myelopathic pain.

  • The radicular pain is mostly secondary to posterolateral herniations that compress spinal nerves as they exit through the intervertebral foramen. Radicular pain will usually radiate towards the dermatome of the nerve roots innervated by the exiting nerve.
  • Myelopathic pain is seen in central herniations. The herniated disc compresses the spinal cord, leading to sensory and/or motor problems in the corresponding compressed area and below. This is particularly more severe in the thoracic spinal cord since the spinal canal in this region is smaller compared to the cervical and lumbar region. Hence, a slight compression will lead to symptoms[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. Three quarters of incidence occurs below T8, with T11-T12 being most common. 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.[1]

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.
MRI HTML.jpg

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.[1]

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.[2]

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[1].

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.[2][3]

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.[2][3][1]

Rule out conditions such as

Pain referred around the chest wall tends to be costovertebral in origin.[4]

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.[4]

Elaboration on some testing

Assess passive movements of the thoracic spine and the end feel:[4]

• 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.[2][5][6] />

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[1]

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.[1]

Physical Therapy Management[edit | edit source]

Massage image.jpg

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.[6][7] Animal model studies show that physical exercise helps in intravertebral disk proliferation, particularly in moderate to high volume low repetition and frequency exercises.[8][9] Most patients (80%) with a prolapsed intervertebral disc respond in 4-6 weeks to conservative therapy.[10][11]

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.[2]

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]

  • Thoracic manip.JPG
    Thoracic discogenic pain syndrome (TDPS) is rare making it challenging for the healthcare team to diagnose and treat the condition.
  • The rarity of TDPS is attributed to the particular orientation, structure, and function of the thoracic spine in the vertebral column.
  • Despite this rarity, physiotherapists, physician assistants, and physicians should be familiar with its diagnosis and treatment and work as an interprofessional team to provide treatment[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.[6] [7]

References[edit | edit source]

  1. ↑ 1.0 1.1 1.2 1.3 1.4 1.5 1.6 1.7 1.8 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)
  2. ↑ 2.0 2.1 2.2 2.3 2.4 Juergen Kraemer, 2009, Intervertebral Disk Diseases: Causes, Diagnosis, Treatment and Prophylaxis , Thieme , Stuttgart, 375p.
  3. ↑ 3.0 3.1 Vanichkachorn JS, Vaccaro AR. Thoracic disk disease: diagnosis and treatment. JAAOS-Journal of the American Academy of Orthopaedic Surgeons. 2000 May 1;8(3):159-69.
  4. ↑ 4.0 4.1 4.2 Magee, D. J. (2008). Orthopedic physical assessment. St. Louis, Mo: Saunders Elsevier. Print
  5. ↑ Shirzadi A, Drazin D, Jeswani S, Lovely L, Liu J. Atypical presentation of thoracic disc herniation: case series and review of the literature. Case reports in orthopedics. 2013;2013.
  6. ↑ 6.0 6.1 6.2 Deitch K, Chudnofsky C, Young M. T2–3 Thoracic Disc Herniation with Myelopathy. The Journal of emergency medicine. 2009 Feb 1;36(2):138-40.
  7. ↑ 7.0 7.1 Manchikanti L, Hirsch JA. Clinical management of radicular pain. Expert review of neurotherapeutics. 2015 Jun 3;15(6):681-93.
  8. ↑ 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. International journal of molecular sciences. 2015 Jan;16(1):2130-44.
  9. ↑ Steele J, Bruce-Low S, Smith D, Osborne N, Thorkeldsen A. Can specific loading through exercise impart healing or regeneration of the intervertebral disc?. The Spine Journal. 2015 Oct 1;15(10):2117-21.
  10. ↑ Hofstee DJ, Gijtenbeek JM, Hoogland PH, van Houwelingen HC, Kloet A, Lötters F, Tans JT. Westeinde sciatica trial: randomized controlled study of bed rest and physiotherapy for acute sciatica. Journal of Neurosurgery: Spine. 2002 Jan 1;96(1):45-9.
  11. ↑ Weber H, Holme I, Amlie E. The natural course of acute sciatica with nerve root symptoms in a double-blind placebo-controlled trial evaluating the effect of piroxicam. Spine. 1993 Sep;18(11):1433-8..
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