Thoracic Radiculopathy

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Original Editors

Top Contributors - Haegeman Nicolas, Rik Van der Hoeven, Kim Jackson, Lucinda hampton, 127.0.0.1, Admin, WikiSysop and Amanda Ager - Van der Hoeven Rik, Henau Laurien, Derick Glenn, Kafkot Nick. 

Search Strategy

Keywords: Thoracic, radiculopathy, thoracic pain, diabetic and thoracic and radiculopathy, thoracic and radiculopathy and physical and therapy, thoracic and radiculopathy
Engine: Pubmed, PEDro, Cochrane

Definition/Description

Thoracic radiculopathy represents an uncommon spinal disorder that is frequently overlooked in the evaluation of spinal pain syndromes

Thoracic radiculopathy is typically caused by mechanical root compression. (1) A radiculopathy is not the same as radicular pain or nerve root pain. The term radiculopathy refers to the whole complex of symptoms that can be caused by a nerve root pathology, such as: paresthesia, hypoesthesia, anesthesia, motor loss, pain and stiffness. Radicular pain indicates a single symptom: pain, which can originate from one or more spinal nerve roots. (2)(3)

Clinically Relevant Anatomy

The most important structures which are involved with a thoracic radiculopathy are: the thoracic vertebrae (T1-T12), the intervertebral disc of the thoracic vertebrae, 12 pairs of spinal nerve roots, posterior rami (innervate the regional muscles of the back) and ventral rami (innervate the skin and muscles of the chest and abdominal area). (4)

Epidemiology /Etiology

The epidemiology of thoracic radiculopathy is unknown. In a lot of cases the diagnosis of thoracic radiculopathy is overlooked. Radiculopathy typically is a mechanical root compression due to diabetes mellitus, degenerative spine changes such as disc herniation and spondylosis. Other possible causes of mechanical root compression are a metastatic tumor, trauma, scoliosis, viral infection/inflammation, connective tissue disease and tuberculosis. Diabetes mellitus (15% insulin-dependent and 13% non-insulin-dependent have diabetic thoracic polyradiculopathy) and disc disease/ herniation are the most common causes of thoracic radiculopathy. (5)(1)

Characteristics/Clinical Presentation

The patients with thoracic radiculopathy often suffer from radicular symptoms such as pain and hyperalgesia, parasthesia, dysthesia and allodynia.
Depending on which nerve root is affected, the loss of sensation will occur in a segmental pattern across the thorax.
Sometimes the patient also will complain from lower limb pain, vague abdominal or chest pain and axial pain.
Thoracic radiculopathy can be suggested when there is an abdominal wall bulging, due to weakness of the abdominal wall muscle. Look out for other symptoms of muscles weakness. (Beevor’s sign and reflexes)
Another symptom which is not always present is the loss of weight, the affected nerve root can affect the intestines.(1)(4)

Differential Diagnosis

The most common form of thoracic radiculopathy is diabetic thoracic polyradiculopathy. Diabetic thoracic polyradiculopathy causes chronic abdominal pain, but there are four disorders who could be confused with diabetic thoracic polyradiculopathy:
- Postherpetic neuralgia
- Chronic abdominal wall pain
- Malignancy
- Other spinal disorders (e.g. spinal cord tumors, compression by intervertebral discs)
(6)
The diagnosis of thoracic radiculopathy can be based upon the characteristic history, physical examination findings, cutaneous sensory examination, paraspinal electromyography and CT-scan of the abdomen (to exclude malignancy). The exclusion of other causes of pain is the most important step in the diagnostic procedure.
Since there are a lot of generators of thoracic pain (see the list below), differentiating these differential diagnoses will be difficult. (4)

Generators of thoracic pain:

• Spinal: Infectious, neoplastic (primary, metastatic), degenerative (spondylosis, spinal stenosis, facet syndrome, disc disease/HNP), metabolic (osteoporosis, osteomalacia), deformity (kyphosis, scoliosis, compression fracture, somatic dysfunction), neurogenic (radiculopathy, Herpes Zoster, anteriovenous malformation)
• Extraspinal: Intrathoracic (cardiovascular, pulmonary, mediastinal), Intra abdominal (Hepatobiliary, gastrointestinal, retroperitoneal), Musculoskeletal (Post-thoracotomy syndrome, polymyalgia rheumatica, myofascial pain syndrome, somatic dysfunction, rib fractures, costochondritis), Neurogenic (Intercostal neuralgia, peripheral polyneuropathy, RSD/CRPS)
  
  

Another difficulty is the differential diagnosis of T1 radiculopathy due to the similarity of clinical findings to C8 radiculopathy. Several characteristics such as diminished sensation in the axilla, motor deficit involving only the intrinsic muscles of the hand, and Horner’s syndrome may distinguish T1 radiculopathy. (5)

Diagnostic Procedures

Because of the broad spectrum of differential diagnosis it is hard to discover the cause of thoracic syndromes, differentiation between the other causes and thoracic radiculopathy is important.
- Electrodiagnosic evaluation: Needle EMG of thoracic paraspinal, abdominal and intercostal muscles can be preformed to help the diagnosis. Fibrillations and positive sharp waves in the paraspinal muscle can provide information about the level at which a problem is located. It is also used to differentiate between diabetic thoracic radiculopathy and other intraabdominal and intrathoracic diseases. (4)(1)(8) This technique is not used often nor is there any evidence that the intercostal muscles add to the diagnosis.(4)
- Imaging: Plain radiographs, MRI, myelography and CT are often used to determine the cause and/or exclude other diagnoses. (4) (1)
- Diagnostic selective nerve root block: injections preformed to confirm or exclude a clinically suspected pain generator. The sensitivity (87%-100%) and specificity (94%-100%) is strongly dependent on the correctness of the preformed technique.(9)

Outcome Measures

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Examination

The first examination is looking for symptoms (already discussed earlier).(7)
Due to non-universal tenderness and the sensory changes, it is not reliable to do a sensory examination. Physical examination is not the best way to evaluate thoracic radiculopathy, unlike the lumbosacral and cervical radiculopathies the affected muscles cannot be tested isolated. Therefore the examination will rather be used to exclude other diagnoses then to determine a thoracic radiculopathy. (4)

Medical Management

Conservative treatment (anti-infl. Med., muscle relaxants, physical applications, exercise) is generally recommended for patients with a thoracic radiculopathy and is effective for one-third of the patients. Acute symptoms can be treated similar to those of a cervical and lumbar radiculopathy. When there are symptoms of progressive myelopathy, neuromuscular comprimise or when incapacitating symptoms continue to exist other treatment is advised.

More invasive procedures are: Epidural steroid injections (no study reporting outcome or efficacy available for thoracic radiculopathy on PubMed) (4)(1),nerve root blocks (90% significant pain relief, only suitable for patients with symptoms at one or two segments)(4)(10), percutaneous disc decompression (used for radiculopathy due to disc herniation) (1), percutaneous vertebroplasty (used to treat compression fractures, although they are usually treated by non interventional techniques) (4).
Surgical treatment : Laminectomy for disc herniation has been disfavored because of a 28% chance to make it worse (4), myelopathic symptoms disappeared in 95% of patients who underwent surgical management for thoracic disc disease (4). We should conclude that for surgical procedures proper patient selection and identification of symptomatic structural pathology is needed. We should avoid open surgery because of the high chance of complications and only use it when conservative and less invasive procedures fail.

Physical Therapy Management

Generally acute symptoms (no sympthoms of progressive myelopathy or neuromuscular compromise) are treated the same way as a cervical or lumbar radiculopathy, the conservative treatment of thoracic radiculopathy includes: short-term bed rest, NSAID, muscle relaxants and physical therapy.
Physical modalities of the therapy include: ice, heat, ultrasound and TENS. These forms of therapy give a short-term symptomatic relief but will have no effect on the long-term development.
Managing the subacute and chronic symptoms of thoracic radiculopathy consists of spinal extension exercises. Unfortunately there are none or few clinical studies about the effectiveness of conservative treatment interventions for thoracic radiculopathy.(4)
The mainstay of treatment of diabetic thoracic polyradiculopathy is symptomatic therapy and includes: antidepressant drugs and transcutaneous nerve stimulation(6)

Key Research

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Resources

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Clinical Bottom Line

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Recent Related Research (from Pubmed)

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References

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