Thoracic Disc Syndrome

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Sarah Harnie -  Lead Editors - Bouzarpour Faryân - Amir Adam - Evelynn Van Hautegem - Alynn De Maeyer

Search strategy

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”
We only used articles of which the full text were available using the university platform.

Definition/Description

The term ‘thoracic syndrome’ refers to all pathological clinical manifestations due to functional (physiopathological) disturbances and degenerative changes of the thoracic motion segments.
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.
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.,
It most often affects the lower thoracic spine, between T9 and T12, because of the greater mobility of these vertebrae.
Thoracic disc is most seen in the third to fifth decades, and is equally seen in men and women.
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 % of the patients had the duration of the symptoms lasting from 6-12 weeks (sub-acute). (18)

Clinically Relevant Anatomy

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.
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.
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
Because the thoracic vertebrae are stabilized by the thoracic cage it reduces mechanical stress on the intervertebral discs of this region. 
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. 
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.
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.
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.
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.

Epidemiology/Etiology

Thoracic disc herniation is a rare event. Of all the herniated discs, less than 1% occur in the thoracic region.  According to another study by M. Scott Linscott, 4-5% of all disc herniations happen in the thoracic region.  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.
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.  The peak age for thoracic disc herniation is 40-50 years, more frequently in men (Arseni & Nash 1960). More than 70% of the thoracic disc herniations are asymptomatic. 
Thoracic disc lesions are primarily degenerative and affects mostly the lower part of the thoracic spine.  
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. 
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.

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. 
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. 

Characteristics/Clinical Presentation

Most of the time the thoracic disc disorders are located in the mid back at the thoracolumbar junction (T8-T12).  Mostly these disc disorders do not cause any symptoms because the disc is almost completely without nociceptive structures. 
If, nevertheless, symptoms are extant, pain is the most common.  The pain can be located in the upper back or radiated in a dermatomal pattern. The pain can be exacerbated when sneezing or coughing.
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.
The pain can also be referred to the retrosternal, retrogastric or inguinal areas which can cause misdiagnoses such as myocardial infarction, cholecystitis or nephrolithiasis.
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. Posterior tears creates local or diffuse back pain and lateral tears can cause radicular pain to visceral of musculoskeletal areas.
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.
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.
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.
A lateral disc herniation can impinge the exiting nerve root and cause radiating chest wall or abdominal pain.
A centro-lateral disc herniation can have a combination of symptoms of upper back pain, radiating pain or myelopathy.
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.
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.
Other rather uncommon symptoms are bladder symptoms such as incontinence.
Most of the thoracic disc herniations are asymptomatic. The most common complaint of these patients is radicular chest pain.

Differential Diagnosis

Thoracic disc herniations are commonly misdiagnosed as cardiac disorders, abdominal problems, gastrointestinal, neoplastic and demyelinating diseases, tumours, ankylosing spondylitis and intercostal neuralgia.(

- 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.

- 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.

- Lumbosacral disc injuries: Collective name for injuries of lumbosacral discs.,,,,,)

- 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.

- 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 ,,)

- Lumbosacral Spondylolisthesis:Spondylolisthesis is defined as forward translation of a vertebral body with respect to the vertebra below ,,,,)
-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.

Diagnostic Procedures

The use of CT in combination with myelography and MRI greatly increased the ability to accurately visualize thoracic spine disorders. 
A myelogram usually indicates the level of the lesion with certainty, although, special projections may be needed.
Today, MRI is the imaging method of choice in the investigation of the thoracic spinal canal.
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.  
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. 
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.

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.
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.

Examination

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]

A completer overview of a manual examination performed by a physiotherapist can be viewed ‘here” (LINK http://www.physio-pedia.com/Thoracic_Examination)

Medical Management

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)

Surgical Approaches for Thoracic Disc Herniation (TDH)(46)(13)
Anterior
• Transthoracic
Trans-sternal
Transpleural (thoracotomy)
Retropleural
With rib resection
Between ribs (using tubular retractor)
• Thoracoscopy
Posterolateral
• Lateral extracavitary
• Costotransversectomy
• Transpedicular
• Transforaminal
• Transfacet pedicle sparing
• Facetectomy
Unilateral
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)

Physical Therapy Management

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

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)

Parts of the therapy are:
Postural training and body-mechanic education:
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:
The meaning of this exercise is to strengthen the weakened back muscles (thoracic area). An example of exercise are wall push-ups, back extension
(20) (48) (levels of evidence 1A, 5)
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]
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:
All actual and symptomatic thoracic disc protrusions in the absence of contraindications should be manipulated.
Contra-indications:
-Relative: Absence of actual symptomatic disc displacement
Self-reducing disc lesion
Monoradicular neurological deficit
-Absolute: Signs and/or symptoms of cord compression
Patients with bleeding disorders
Patients on anticoagulant treatment
Techniques:
Thoracic manipulations are always performed under strong traction.
3 main types of procedure are considered:
1: Extension techniques, in which extension is always present, sometimes combined with rotation.

2: Rotation techniques, in which rotation is the only component.
3: High thoracic technique, used only in upper thoracic disc lesions
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:
It should be accepted that either the diagnosis is wrong or the disc lesion is not suitable for manipulation.
When the diagnosis is wrong, one must consider possibilities, like: Facet joint, tumour, muscular lesion, osseous Lesion, ligamentous lesion, visceral disorder. [5]
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:
Three groups of indications:
- Patients who present with much discomfort but with very minor articular signs on clinical examination.
- 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.
- Patients who cannot tolerate the extension or rotation techniques. [11] (level of evidence 3B)

Key Evidence

• H. Yoshihara, Surgical Treatment for Thoracic Disc Herniation, An Update. Spine 2014;39:E406–E412.
• 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
• 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.

Resources

1. ↑ 1.0 1.1 1.2 Juergen Kraemer, 2009, Intervertebral Disk Diseases: Causes, Diagnosis, Treatment and Prophylaxis , Thieme , Stuttgart, 375p.
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.
3. ↑ 3.0 3.1 3.2 3.3 http://www.mdguidelines.com/degeneration-thoracic-or-thoracolumbar-intervertebral-disc
4. ↑ http://www.spineuniverse.com/conditions/degenerative-disc/anatomy-degenerative-disc-disease (level of evidence 5)
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.
6. ↑ Lyu RK, Chang HS, Tang LM, Chen ST. Thoracic disc herniation mimicking acute lumbar disc disease. Spine. 1999; 24 (4): 416-418
7. ↑ Cyriax J. textbook of orthopaedic medicine, vol 1, diagnosis of soft tissue lesions, 8th edn. Ballière Tindall, London, 1982. (level of evidence 5)
8. ↑ J. MCInerney, P. A. Ball. The pathophysiology of thoracic disc disease. Neurosurg. Focus Volume 9 , 2000 (level of evidence 3A)
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)
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)
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)
12. ↑ Maitland G, Brewerton D. Vertebral manipulation. Butterworth, London, 1977:7.
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
14. DS McNally et al, Intervertebral disc structure: observation by a novel use of ultrasound imaging, Ultrasound in Medicine & Biology, Volume 26, Issue 5, June 2000, Pages 751–758 (level of evidence 3A)
15. PW Stratford et al, Development and Initial Validation of the Back Pain Functional Scale, The Journal of rheumatology, 2000 (level of evidence 2B)
16. Courtney W. Brown et al; The natural history of thoracic disc herniation, Spine Volume 17 - number 6 supplement; 1992 ( 4)
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)
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)
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)
20. Joshua A. Cleland et al ;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)
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
LEVEL OF EVIDENCE 4
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
LEVEL OF EVIDENCE 1A
23. DENNIS G. VOLLMER, M.D., AND NATHAN E. SIMMONS, M.D.; Transthoracic approaches to thoracic disc herniations; Neurosurg Focus 9 (4):E8, 2000
LEVEL OF EVIDENCE 5
24. Schellhas KP, Pollei SR, Dorwart RH. Thoracic discography. A safe and reliable technique. Spine. 1994 Sep 15. 19(18):2103-9.
LEVEL OF EVIDENCE 2b
25. http://twinboro.com/body/spine/thoracic/disc/conditions/thoracic-degenerative-disc-disease-nj.html LEVEL OF EVIDENCE 5
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
LEVEL OF EVIDENCE 2b
27. RC O’Connor et al, Thoracic radiculopathy, Phys Med Rehabil Clin N Am 13 (2002) 623–644 (level of evidence 2A)
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)
29. NE Epstein et al, Thoracic Spinal Stenosis: Diagnostic and Treatment Challenges, Journal of Spinal Disorders, June 1994 (level of evidence 4)
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)
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)
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)
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)
34. Giuseppe Guglielmi, Osteoporosis and Bone Densitometry Measurements, Springer, 2013 pages 51-52 (level of evidence 3A)
35. http://neuroscience.uth.tmc.edu/s2/chapter03.html (level of evidence 5)
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)
37. G. Sheean, The pathophysiology of spasticity. European Journal of Neurology 2002, 9 (Suppl. 1): 3–9. (level of evidence 5)
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)
39. http://www.rehabmeasures.org/Lists/RehabMeasures/PrintView.aspx?ID=1033(level of evidence 5)
40. http://www.medicalcriteria.com/site/en/criteria/64-neurology/238-neuromrc.html(level of evidence 5)
41. http://www.erasmusmc.nl/cs-fysiotherapie/beeld/4887961/h.emnsa(level of evidence 5)
42. http://www.rehabmeasures.org/Lists/RehabMeasures/PrintView.aspx?ID=902 (level of evidence 5)
43. http://www.ncbi.nlm.nih.gov/books/NBK397/(level of evidence 5)
44. http://www.ncbi.nlm.nih.gov/books/NBK396/(level of evidence 5)
45. http://www.ipphysio.com/documents/Pelvic%20Floor%20Grading%20Systems.pdf(level of evidence 5)
46. H. Yoshihara, Surgical Treatment for Thoracic Disc Herniation, An Update. Spine 2014;39:E406–E412.(level of evidence 2A)
47. http://www.bodybuilding.com/fun/beginner-core-training-guide.htm (level of evidence 5)
48. http://www.bodybuilding.com/fun/beginner-back-training-guide.htm (level of evidence 5)
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 )

• http://www.spineuniverse.com/sites/default/files/imagecache/gallery-large/wysiwyg_imageupload/3998/2015/04/02/DDD_labeled.jpg (foto disc deseases)
• http://keckmedicine.adam.com/graphics/images/en/19469.jpg (disc anatomy Adam)
• Video link: explanation thoracic herniation disc : http://www.spine-health.com/video/thoracic-herniated-disc-video 

Case Studies

add links to case studies here (case studies should be added on new pages using the <a href="Template:Case Study">case study template</a>)

Clinical Bottom Line

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.