Thoracic Disc Syndrome

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Search strategy

Information concerning ‘thoracic disc syndrome’ was collected by using article databases, such as Pubmed, Web of Knowledge, Google Scholar, and books from the medical library at the VUB.
The key words used are : ‘thoracic disc syndrome/ disease/ lesion/ injury/ herniation’, ‘syndrome of the prolapsed thoracic intervertebral disc’, ‘thoracic discogenic pain syndrome’ and ‘thoracic degenerative disc disease’. These terms are all synonyms for ‘thoracic disc syndrome’.
The most successful keywords were Thoracic Disc Disease and Thoracic Disc Herniation.

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 syndrome is most seen in the third to fifth decades, and is equally seen in men and women.

Clinically Relevant Anatomy

Clinically relevant for this condition are the thoracic spine (T1-T12) and the intervertebral discs between the vertebrae. 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. 

Epidemiology/Etiology

The development of thoracic disc degeneration is not well defined. As in the cervical and lumbar spines, thoracic disc degeneration is part of normal aging. 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

Disc degenerations and minor disc herniations themselves are often (not always) painless because the disc is almost completely without nociceptive structures. Clinical syndromes (only 15% is specific, 85% is non-specific low back pain) originate only when a subluxated fragment of disc tissue pressures on the dura mater or on the dural nerve root sleeve. In this case you observe neurologic symptoms. 
Disc displacements are either annular or nuclear and may have posterocentral or posterolateral localization.
Posterocentral: Compression of the dura mater leading to multisegmental pain, mainly referred into the posterior thorax, but may also spread in the anterior chest, abdomen and lumbar area. 
Posterolateral: Interfering with the dural sleeve around the nerve root results in pain that is segmentally referred into the corresponding dermatome. 
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. ,

Thoracic disc syndrome may give rise to 4 different clinical presentations:
(1) chronic thoracic backache
(2) acute thoracic lumbago
(3) Thoracic root pain
(4) spinal cord compression 
The result may be
(in 1) pain in the thoracic region of the upper back;
(in 2) pain that follows a rib;
(in 3) lower extremity weakness,
(in 4) spasticity and lack of coordination and bowel or bladder control impairment. , 

Differential Diagnosis

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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. 

Outcome Measures

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. 11

Examination

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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

Physical Therapy Management

Manual therapists and osteopaths claim that almost all thoracic disc protrusions can be reduced by manipulation in 3 to 5 sessions. 6
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. 6

Manipulations

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: Sings 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. 6

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 witch 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

Key Evidence

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Resources

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Case Studies

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Clinical Bottom Line

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