Thoracic Discogenic Syndrome

What is Thoracic Discogenic Syndrome?

Thoracic discogenic syndrome, a condition caused by issues in the discs of your mid-back or thoracic spine, can be hard to diagnose because it’s not very common. This is due to the specific way the thoracic spine is built and functions, making it less mobile and less likely to be affected by disc problems. Your spine has natural curves; two areas – behind the chest (thoracic spine) and at the tailbone (sacrum) curve outward, and two areas – in the neck (cervical spine) and lower back (lumbar spine) curve inward, developed around puberty.

The areas that arch inward (cervical and lumbar) carry most of the body weight, so the areas that arch outward (thoracic and sacral) are less likely to experience disc degeneration, a common cause of disc-related pain. Between every two vertebrae in your spine, there’s a disc made up of a tough outer ring (annulus fibrosis), a jelly-like centre (nucleus pulposus), and endplates that sit on either side of the disc next to the vertebrae. These discs absorb shock and allow your spine to move. As we age, these discs can wear out and the jelly-like center can push out through the outer ring, possibly causing nerve pain or compression, leading to symptoms like numbness or weakness.

People with this condition might not show any symptoms or they might feel pain that could progress to numbness or weakness. The pain could be anywhere from the chest, upper and lower abdomen, arms, groin to legs, this makes it tricky to pinpoint the condition. The condition is confirmed with an MRI scan. It’s not uncommon to find thoracic disc herniations in people who don’t have symptoms when scanning with MRI. Treatments usually include improving posture, strengthening muscles, and taking preventive measures. Surgery is considered when patients show severe symptoms or when severe pain remains after treatment.

However, conducting a disc removal surgery in the thoracic spine is a complex task. The spinal canal, which houses the nerves, is relatively narrow here, and the spinal cord isn’t as free to move as it is in the lower back. Therefore, surgeons have to be very careful to avoid damaging the spinal cord during surgery. There are various surgical options, each with its own pros and cons.

What Causes Thoracic Discogenic Syndrome?

Degenerative changes, or wear and tear, are the main cause of a condition known as thoracic discogenic syndrome. As people get older, the disc between the bones in our spine loses its water content. This leads to the disc weakening and not being able to handle the pressure exerted on the spine. This process can eventually lead to conditions such as disk herniations (where the disc bulges out), annular tears (tears in the outer layer of the disc), and the degeneration of endplates (the top and bottom surfaces of the bones in the spine). These deteriorating discs can press on nerves and the spinal cord, causing pain and discomfort.

While the main cause of thoracic discogenic syndrome is aging, trauma or injury to the upper spine can also cause this condition in about 10% to 20% of cases. Activities such as golf, softball, and baseball, which require twisting of the spine, can increase the risk of experiencing a spine disc herniation, particularly in the upper back or thoracic region of the spine.

Risk Factors and Frequency for Thoracic Discogenic Syndrome

Thoracic disk herniations, which are usually not associated with any symptoms, are quite rare and are often discovered by chance during MRI scans. Studies from autopsies in the US show that these happen in around 7% to 15% of cases. Imaging studies present a varying incidence rate from 11% to 37%, which changes depending on the imaging tool used.

Only about 0.3% to 0.8% of all cases of symptomatic disk diseases are made up of symptomatic thoracic disk disease. The majority, nearly 80% of people affected, start showing symptoms in their thirties or forties. With 75% of the cases, the affected disks are usually located below the T8-T9 disk level, with the T11-T12 level being the most often affected.

0.3% to 0.8% of all symptomatic disk diseases cases are symptomatic thoracic disk disease.
Almost 80% of the affected people start showing symptoms in their 30s or 40s.
About 75% of the affected disks are located below the T8-T9 disk level.
The most commonly affected level is the T11-T12 disk.

The number of patients who show detectable signs upon examination is about 1 in 1 million every year. Disk disease related to the thoracic region results in quite fewer hospital admissions, with a range of 0.13% to 0.15%. They make up between 0.2% to 4% of all diskectomies.

Signs and Symptoms of Thoracic Discogenic Syndrome

Thoracic disk herniations are typically found by accident during MRI scans as they do not always cause symptoms. If you do experience symptoms, it can be challenging to diagnose because these symptoms are often unconventional and can be mistaken for other problems. Diagnosis requires a thorough review of the individual’s health history and a comprehensive physical examination. Key factors include understanding the nature, severity, and spread of the pain and what makes it better or worse.

The primary symptom associated with thoracic discogenic syndrome is usually a dull pain in the chest area. Depending on the location of the herniations, they can feel like lower neck pain or upper lower back pain. Sometimes, the pain may radiate to other areas such as the chest, behind the sternum, or the groin. This makes diagnosis more complex because it could seem like heart disease, gallbladder inflammation, a hernia, or kidney stones.

If the disk herniation presses on the nerve roots or the spinal cord itself, the pain often evolves to take on a radicular, myelopathy-like quality. Radicular pain is a type of nerve pain that radiates to other areas of the body, and myelopathic pain relates to spinal cord damage.

Tears in the disk can also cause different types of pain, depending on their location. Tears that occur at the front might result in chest, rib, or visceral pain. Lateral (sideways) tears can cause radiating pain in either visceral or musculoskeletal locations, while posterior (back) tears usually cause generalized or diffuse back pain.

There are four primary locations where thoracic disk herniations may occur:

Central thoracic disk herniations often lead to spinal cord compression and symptoms related to damage to the spinal cord (myelopathy). Symptoms could include muscle stiffness, abnormal reflexes, walking problems, and loss of bladder or bowel control.
Centrolateral herniations can cause weakness on one side of the body and pain or loss of sensation on the other, mimicking a condition known as Brown-Sequard syndrome.
Lateral thoracic disk herniations are most likely to cause radiating pain due to compression of exiting spinal nerves. The pain often follows the distribution pattern of the affected dermatome (skin area supplied by a specific nerve).
Intradural herniations, which occur within the dura mater (a layer protecting the spinal cord and brain), are rare.

In people suffering from nerve root compression, the pain often follows a dermatome distribution. This pain is usually described as burning, electric, or shooting. Here are some typical distributions:

T1 nerve root compression – pain radiating to the inner part of the forearm.
T2 nerve root compression – pain radiating to the armpit.
T4 nerve root compression – pain radiating to the nipple area.
T10 nerve root compression – pain radiating to the navel.
T12 nerve root compression – pain just above the groin ligaments.

About a quarter of patients could also experience numbness or other abnormal sensations. These sensations also follow a dermatome distribution.

Patients affected by spinal cord compression may experience myelopathy, causing pain and abnormal sensations anywhere below the level of the affected spinal cord area. Other symptoms may include numbness and weakness in the lower body, abnormalities in walking, heightened reflexes, and in severe cases, paralysis. Some patients might only show isolated sensory symptoms. Some notable signs of a potential spinal fluid leak due to a tear in the protective covering of the spinal cord and brain (dura) from a disc include the combination of lower pressure inside the skull while standing, lower blood pressure, and headaches.

Finally, some patients may present with weakness as their only symptom. Weakness in the abdominal wall and the muscles between the ribs can often be a late sign with weakness in the lower body due to myelopathy being more common. A sign of severe myelopathy is bowel or bladder incontinence, but this is rare and only occurs in about 2% of patients.

A physical examination typically starts with examining the neck, chest, and lower back areas, as well as the hips and stomach. Signs might include pain in the muscles, inflexibility, and weakness. Tests for sensation and muscle strength are also crucial. For example, a lesion at the T9 and T10 nerve roots could paralyse the lower abdominal muscles, resulting in an upward movement of the belly button when the abdomen is contracted. This is known as the Beevor sign.

Testing for Thoracic Discogenic Syndrome

Diagnosing thoracic discogenic syndrome, a condition which affects your spinal discs, involves a thorough check of your muscles, bones, and nerves. The first step in examining this condition may be regular X-rays. While these X-rays won’t necessarily show if you have a herniated or slipped disc, they can show useful information such as fractures, tumors, dislocations, and infections. If your x-ray shows osteophytes (bone spurs) or a narrowing space between your spinal discs, that may suggest you have degenerative disc disease.

Typically, about 70% of people with thoracic disc herniation (a condition where the soft inner portion of the disc protrudes through the outer ring) have a calcification or hardening of their thoracic discs. This makes calcification a reliable sign of thoracic disc herniation. However, it’s important to note that just 4 to 6% of people with neck or lower back herniations show this calcification.

While X-rays are a good first step, technology like MRI scans has made diagnosing disc problems easier and more detailed. Computed Tomography (CT) scans, which were previously used often, now take a backseat to MRI. Although, CT scans can be useful for identifying lateral disc herniations, showing calcifications, and helping to map out surgeries.

MRI is the preferred method because it can easily showcase the surrounding tissues, providing a clear image for diagnosis. Additionally, MRI can detect thoracic disk herniations effectively. But an MRI, even as advanced and helpful as it is, cannot tell how the condition will progress or assess how significant the identified lesions are. Also, it’s less sensitive in detecting annular tears, especially in the thoracic region, which is why doctor-patient conversation and physical examination are still vital.

A classification system for thoracic disk herniations has been proposed, with five different types categorized based on size, location, and how they affect the spinal cord or nerve root. Tests like nerve conduction studies, needle electromyography, and somatosensory evoked potentials can help provide more diagnostic information. They’re useful for ruling out other diagnoses but because they can’t pinpoint the level of the problem and because they carry certain risks, they are not the primary tool used for diagnosis.

A diskogram may be conducted where contrast material is injected into the disc to see if the patient’s pain is similar to their complaints. If the resulting pain suggests that the disc is the source of the problem, diskograms become most valuable.

Treatment Options for Thoracic Discogenic Syndrome

The first attempt to treat thoracic discogenic syndrome, which causes back pain due to a damaged disc in the spine, uses rest, anti-inflammatory drugs, and physical therapy. The main goal is to lower pain, and rehab focuses on adjusting day-to-day activities to maintain proper posture and body movements. This would help prevent more harm to the spine and reduce pressure caused by activities like sitting, bending, or lifting heavy items.

After the initial treatment stage, healing moves into a recovery stage where rehab focuses on strength exercises, and continues the attention to maintaining correct posture and body movements. It may be necessary for patients to take pain management medications during this time to help them participate in their therapy sessions.

Sometimes, despite initial treatments, a patient might continue to feel a lot of pain. In this case, they may undergo injections of steroids into the epidural region of the spine. Generally, these injections are repeated one to three times, each lasting about a month apart. However, if the first injection doesn’t provide relief, a second one isn’t recommended.

The medications used in this treatment process can vary. This can include non-opioid pain relievers, opioids for those who haven’t responded to other medications, muscle relaxers, and corticosteroids. However, it’s important to note that these drugs can have side effects and may not be suitable for all patients. The choice of medication always depends on the individual circumstances of the patient.

If these non-surgical treatments don’t work, surgery might be necessary. However, there’s no universally accepted approach to this surgery; the specific method used depends on the individual’s circumstances. Sometimes, surgeons may need to locate a specific artery, the Adamkiewicz artery, to determine the right approach for surgery.

Lastly, there’s been some discussion and study into using techniques that are less invasive for thoracic disk surgery, like using an endoscope, compared to conventional methods. While these techniques can reduce trauma during surgery and lead to quicker recovery times, they also have limitations like a steep learning curve for the surgeon and could potentially be more expensive.

When trying to diagnose thoracic discogenic syndrome, which involves discomfort in the middle of the back due to disc damage, physicians might also consider these potential diagnoses:

Mechanical back pain
Discal cyst (a fluid-filled sac on a disc)
Synovial cyst (a fluid-filled sac on a joint)
Osteophytes (bone spurs)
Cholecystitis (gallbladder inflammation)
Nephrolithiasis (kidney stones)
Myocardial infarction (heart attack)
Osteoma (benign bone tumour)
Metastasis (cancer spread)
Epidural hematoma (bleeding in the spinal area)
Lumbosacral radiculopathy (nerve root issue in lower back)
Cervical radiculopathy (nerve root issue in neck)
Cervical disk injury (damaged disc in the neck)
Lumbar disk injury (damaged disc in the lower back)
Lumbosacral spondylolysis (stress crack in lower back bone)
Lumbosacral spondylolisthesis (slipped vertebra in lower back)
Lumbosacral discogenic syndrome (lumbar disc pain)
Osteodiscitis with abscess (bone disc inflammation with pus-filled cavity)
Benign intra-axial tumors such as a meningioma or schwannoma (non-cancerous growths in the brain or nerves)

The physician carefully considers all these conditions during diagnosis, to make sure they identify the correct medical issue.

What to expect with Thoracic Discogenic Syndrome

About 80% of patients can return to their normal activities by following non-surgical treatments. However, for those who continue to experience severe pain, symptoms in both sides of the body, or nervous system problems, surgery may often be required.

Surgery for slipped disks in the chest area can lead to various outcomes:

About half the patients might see improvements in their nervous system health.
About 40% of these patients might maintain the stability of their spine.
Unfortunately, for about 5% of patients, their nervous system health might worsen.

Possible Complications When Diagnosed with Thoracic Discogenic Syndrome

The occurrence of complications after surgery ranges from 20% to 30%. Here are some complications that can potentially happen:

The possibility of pneumonia and other lung-related complications is higher during anterior surgical approaches.
The pneumonia rate is higher in patients who underwent an anterior surgical approach, at 6%, compared to 1%, 3%, and 0% in cases of lateral, transpedicular, and laminectomy approaches, respectively.
There could be a potential issue with the spinal cord.
Symptoms might potentially worsen after the surgery.
The spine might lose stability in certain segments.
Radiation hazards may be present following the usage of fluoroscopy during surgery.
There is a possible recurrence of symptoms, which ranges between 0.5% and 25%.
Increase in pressure in the skull and instances of seizures can occur, especially following saline perfusion in endoscopic surgeries.
Cerebrospinal fluid may leak or a pseudomeningocele, a collection of cerebrospinal fluid, could form due to any potential tears in the dural membrane.
Patients might experience sharp, shock-like pain with intercostal neuralgia.
There are potential cases of patients experiencing progressive neurological deficits, notably in 23% of cases. This could primarily be due to reduced blood pressure, pressure from surgical instruments, or a possible blood clot in the epidural region.
Abdominal faux-hernias may occur.
Horner syndrome, a possible nerve disorder, might happen in some patients.

Additionally, it’s worth noting that orthopedic surgeons, in comparison to urology and plastic surgeons, have double the rate of expected total cancers and almost triple the rate of expected breast cancers.

Endoscopic surgical techniques are increasingly popular as they have a lower rate of complications at 20% compared to traditional open surgical techniques. A study looking at endoscopic techniques showed that there were no instances of infection or death. The complications from this type of surgery were limited to dural tears (1.3%), abnormal sensations (4.7%), recurring disk herniation (2.9%), spinal cord disease (2.1%), blood clots in the epidural region (1.1%), and the surgery needing to be done again (1.7%).

Preventing Thoracic Discogenic Syndrome

Most people who have a condition called a ‘thoracic disk herniation’ (a problem with one of the disks in the mid to upper part of the spine) don’t show any symptoms and don’t need treatment. This disc herniation can cause a rare type of back pain known as ‘thoracic discogenic syndrome’, which is often difficult to diagnose. This condition is typically caused by the wear and tear of the disks between the spinal bones in your upper back. Sometimes, it can also happen in athletes who play sports that involve a lot of twisting movements.

The first sign of thoracic discogenic syndrome is usually back pain, which can become more severe over time and lead to other problems, such as radiculopathy or myelopathy. Radiculopathy refers to pain, weakness, or numbness caused by irritation or damage to the nerves, while myelopathy is a disease of the spinal cord.

Imaging tests such as X-rays, MRI scans, and CT scans play an important part in diagnosing this condition. X-rays can help to rule out other issues like fractures, tumors, dislocations, and infections. They can also show hints of the degenerative disk disease. MRIs are usually the first type of imaging ordered. CT scans can provide more detailed information, which is especially helpful for doctors when planning surgery.

The first step in treating thoracic discogenic syndrome is usually conservative, involving anti-inflammatory drugs and a rehab program to help protect the injured area and prevent further problems. As the symptoms improve, the focus will shift to proper body movements and posture. The last phase of rehabilitation focuses on strengthening the muscles that support the back, buttocks, and belly to help maintain improvement and prevent future issues.

If anti-inflammatory drugs don’t work or can’t be used for some reason, acetaminophen might be an alternative, although it might not be very effective. Muscle relaxants can be used along with anti-inflammatory drugs for better results. In some cases, low doses of opioids may be used to help manage the pain. The goal is to make the pain manageable so you can actively participate in your rehab program. Other options include non-narcotic pain relievers like Tramadol and antidepressants like Duloxetine, which can be helpful for chronic low back pain and may help with thoracic discogenic syndrome too.

If the condition doesn’t improve with conservative treatment or causes other related issues to the spinal cord or nerves, surgery might be needed. For patients who can’t have, or don’t want to have, surgery, steroid injections into the spine might be an option

Frequently asked questions

The prognosis for Thoracic Discogenic Syndrome varies depending on the individual case. However, the majority of patients, about 80%, can return to their normal activities by following non-surgical treatments. For those who continue to experience severe pain, symptoms on both sides of the body, or nervous system problems, surgery may be required. The outcomes of surgery for slipped disks in the chest area can vary, with about half of patients seeing improvements in their nervous system health, about 40% maintaining the stability of their spine, and unfortunately, about 5% experiencing a worsening of their nervous system health.

The main cause of Thoracic Discogenic Syndrome is degenerative changes or wear and tear on the disc between the bones in the spine, which occurs as people get older. Trauma or injury to the upper spine can also cause this condition in some cases.

Signs and symptoms of Thoracic Discogenic Syndrome include: - Dull pain in the chest area, which can feel like lower neck pain or upper lower back pain. - Radiating pain to other areas such as the chest, behind the sternum, or the groin. - Radicular pain, which is a type of nerve pain that radiates to other areas of the body. - Myelopathic pain, which relates to spinal cord damage. - Different types of pain depending on the location of tears in the disk: - Front tears can result in chest, rib, or visceral pain. - Lateral tears can cause radiating pain in either visceral or musculoskeletal locations. - Posterior tears usually cause generalized or diffuse back pain. - Specific symptoms based on the location of thoracic disk herniations: - Central herniations can lead to spinal cord compression and symptoms such as muscle stiffness, abnormal reflexes, walking problems, and loss of bladder or bowel control. - Centrolateral herniations can cause weakness on one side of the body and pain or loss of sensation on the other, resembling Brown-Sequard syndrome. - Lateral herniations are most likely to cause radiating pain following the distribution pattern of the affected dermatome. - Intradural herniations, which occur within the dura mater, are rare. - Nerve root compression can result in pain following a dermatome distribution, described as burning, electric, or shooting. - Numbness or abnormal sensations may also occur following a dermatome distribution. - Spinal cord compression can cause myelopathy, leading to pain and abnormal sensations below the affected spinal cord area, as well as numbness, weakness in the lower body, abnormalities in walking, heightened reflexes, and, in severe cases, paralysis. - Weakness in the abdominal wall and muscles between the ribs can be a late sign, with weakness in the lower body being more common. - Severe myelopathy may result in bowel or bladder incontinence, although this is rare. - Physical examination signs may include muscle pain, inflexibility, weakness, and specific tests for sensation and muscle strength, such as the Beevor sign, which involves the upward movement of the belly button when the abdomen is contracted.

The types of tests that are needed for Thoracic Discogenic Syndrome include: - Regular X-rays: These can show fractures, tumors, dislocations, infections, osteophytes (bone spurs), and a narrowing space between spinal discs. - MRI scans: These provide a clear image of the surrounding tissues and can effectively detect thoracic disc herniations. - Computed Tomography (CT) scans: These can be useful for identifying lateral disc herniations, showing calcifications, and helping to map out surgeries. - Nerve conduction studies, needle electromyography, and somatosensory evoked potentials: These tests can provide more diagnostic information and help rule out other diagnoses. - Diskogram: This involves injecting contrast material into the disc to see if the patient's pain is similar to their complaints, which can help determine if the disc is the source of the problem.

The doctor needs to rule out the following conditions when diagnosing Thoracic Discogenic Syndrome: - Mechanical back pain - Discal cyst (a fluid-filled sac on a disc) - Synovial cyst (a fluid-filled sac on a joint) - Osteophytes (bone spurs) - Cholecystitis (gallbladder inflammation) - Nephrolithiasis (kidney stones) - Myocardial infarction (heart attack) - Osteoma (benign bone tumor) - Metastasis (cancer spread) - Epidural hematoma (bleeding in the spinal area) - Lumbosacral radiculopathy (nerve root issue in lower back) - Cervical radiculopathy (nerve root issue in neck) - Cervical disk injury (damaged disc in the neck) - Lumbar disk injury (damaged disc in the lower back) - Lumbosacral spondylolysis (stress crack in lower back bone) - Lumbosacral spondylolisthesis (slipped vertebra in lower back) - Lumbosacral discogenic syndrome (lumbar disc pain) - Osteodiscitis with abscess (bone disc inflammation with pus-filled cavity) - Benign intra-axial tumors such as a meningioma or schwannoma (non-cancerous growths in the brain or nerves)

The side effects when treating Thoracic Discogenic Syndrome can include: - Possibility of pneumonia and other lung-related complications, especially during anterior surgical approaches - Higher pneumonia rate in patients who underwent an anterior surgical approach compared to other approaches - Potential issues with the spinal cord - Symptoms potentially worsening after surgery - Loss of stability in certain segments of the spine - Radiation hazards from fluoroscopy during surgery - Possible recurrence of symptoms - Increase in pressure in the skull and instances of seizures, especially following saline perfusion in endoscopic surgeries - Cerebrospinal fluid leakage or formation of a pseudomeningocele - Sharp, shock-like pain with intercostal neuralgia - Potential cases of progressive neurological deficits - Abdominal faux-hernias - Horner syndrome, a possible nerve disorder - Orthopedic surgeons have a higher rate of expected total cancers and breast cancers compared to urology and plastic surgeons.

You should see a doctor specializing in orthopedics or neurosurgery for Thoracic Discogenic Syndrome.

Thoracic Discogenic Syndrome is quite rare, making up only about 0.3% to 0.8% of all cases of symptomatic disk diseases.

Thoracic Discogenic Syndrome is treated through a combination of rest, anti-inflammatory drugs, and physical therapy. The initial treatment stage focuses on lowering pain and adjusting day-to-day activities to maintain proper posture and body movements. If initial treatments are not effective, injections of steroids into the epidural region of the spine may be used. Medications used in the treatment process can vary, including non-opioid pain relievers, opioids, muscle relaxers, and corticosteroids. If non-surgical treatments do not work, surgery may be necessary, with the specific method depending on the individual's circumstances. Less invasive techniques, such as using an endoscope, have also been studied as potential options for surgery.

Thoracic Discogenic Syndrome is a condition caused by issues in the discs of the mid-back or thoracic spine. It is characterized by disc degeneration, which can lead to nerve pain or compression, resulting in symptoms like numbness or weakness. Diagnosis can be challenging due to the specific structure and function of the thoracic spine.