Overview

 

A rise in the use of magnetic resonance imaging (MRI) has led to the discovery that many people, perhaps as many as 15 percent of Americans, have a thoracic disc herniation. Seeing a herniated thoracic disc on MRI is often incidental, meaning it shows up when the person has MRI testing for another problem.

Although people often refer to a thoracic disc herniation as a slipped disc, the disc doesn't actually slip out of place. Rather, the term herniation means that the material in the center of the disc has squeezed out of the normal space. In the thoracic spine, this condition mostly affects people between 40 and 60 years old.

Few people with a thoracic disc herniation feel any symptoms or have any problems as a result of this condition. In rare cases when symptoms do arise, the main concern is whether the herniated disc is affecting the spinal cord.

Degeneration of the disc can be seen as a change in the signal on an MRI scan as the physical consistency of the nucleus becomes even softer. This naturally occurring process results in softening of the disc over many years of living. Absent some major accident, degeneration must be present for a disc herniation to happen.

As the softened material becomes more fluid and deformable, the weight and forces on the spine during movements which squeeze and flex the disc between the vertebral bodies cause the nucleus to try to bulge outward. Sometimes the annulus is thinned out or pushed ahead of the deforming nucleus material.

Sometimes a piece of the nucleus works its way through a crack in the annulus. I like to describe it as a jelly doughnut being squeezed and the innards coming out. In my practice, most thoracic disc herniations have less clear relationship to accidents or strain injuries than we see with cervical or lumbar disc herniations but it is certainly possible that one could occur this way.

As with other portions of the spine, a herniated thoracic disc is usually the final result of movements and accumulated physical stresses of the spine over the course of many years. Occasionally, a single event seems to mark the onset of symptoms.

Anatomy

What parts of the spine are involved?

The human spine is formed by 24 spinal bones, called vertebrae. Vertebrae are stacked on top of one another to create the spinal column. The main section of each vertebra is a round block of bone, called the vertebral body.

The thoracic spine is made up of the middle 12 vertebrae. Doctors often refer to these vertebrae as T1 to T12. The thoracic spine starts at the base of the neck. The lowest vertebra of the thoracic spine, T12, connects below the bottom of the rib cage to the first vertebra of the lumbar spine, called L1.

The upper half of the thoracic spine is much less mobile than the lower section, making disc herniations in the upper thoracic spine rare. About 75 percent of thoracic disc herniations occur from T8 to T12, with the majority affecting T11 and T12.

Blood vessels that run up and down the spine nourish the spinal cord. However, only one vessel, the anterior spinal artery, goes to the front of the spinal cord in the area between T4 and T9. Doctors call this section of the spine the critical zone. If this single vessel is damaged, as can happen with pressure from a herniated thoracic disc, the spinal cord has no other way to get blood. Left untreated, this section of the spinal cord dies, which can lead to severe problems of weakness or paralysis below the waist.

Healthy discs work like shock absorbers to cushion the spine. They protect the spine against the daily pull of gravity and during activities that put strong force on the spine, such as jumping, running, and lifting.

The spinal canal is a hollow tube inside the spinal column. It surrounds the spinal cord as it passes through the spine. The spinal cord is similar to a long wire made up of millions of nerve fibers. Just as the skull protects the brain, the bones of the spinal column protect the spinal cord. The spinal canal is narrow in the thoracic spine. Any condition that takes up extra space inside this canal can injure the spinal cord.

The intervertebral disc is a specialized connective tissue structure that separates the vertebral bodies. The disc is made of two parts. The center, called the nucleus, is spongy. It provides most of the disc's ability to absorb shock. The nucleus is held in place by the annulus, a series of ligament rings surrounding it. Ligaments are strong connective tissues that attach bones to other bones.

Symptoms

What does the condition feel like?

Symptoms of thoracic disc herniation vary widely. Symptoms depend on where and how big the disc herniation is, where it is pressing, and whether the spinal cord has been damaged.

Pain is usually the first symptom. The pain may be centered over the injured disc but may spread to one or both sides of the mid-back. Also, patients commonly feel a band of pain that goes around the front of the chest. Patients may eventually report sensations of pins, needles, and numbness. Others say their leg or arm muscles feel weak. Disc material that presses against the spinal cord can also cause changes in bowel and bladder function.

Disc herniations can affect areas away from the spine. Herniations in the upper part of the thoracic spine can radiate pain and other sensations into one or both arms. If the herniation occurs in the middle of the thoracic spine, pain can radiate to the abdominal or chest area, mimicking heart problems. A lower thoracic disc herniation can cause pain in the groin or lower limbs and can mimic kidney pain.

Diagnosis

History and Physical Exam

Diagnosing a herniated nucleus pulposus begins with a complete history of the problem and a physical exam.

Your doctor will want to make sure that you are aware when you have to urinate or have a bowel movement. If there is a problem, it could indicate that a herniated disc in the thoracic spine is pushing against the spinal cord.

Diagnostic Tests

X-rays

The doctor may suggest taking X-rays of your mid back. Regular X-rays can't show a herniated disc, but they can give your doctor an idea of how much wear and tear is present in the spine. X-rays can also show a disc that has become calcified, as often happens to a herniated thoracic disc. If part of the calcified disc appears to be pointing into the spinal cord, it's a good indication the thoracic disc is herniated.


MRI

The most common test to diagnose a thoracic herniated disc is the MRI scan. This test is painless and very accurate. It is usually the preferred test to do (after X-rays) if a herniated thoracic disc is suspected.


CT Scan

Sometimes, the X-ray and MRI do not tell the whole story. Other tests may be suggested. A myelogram, usually combined with a CT scan, may be necessary to give as much information as possible.

Treatment

What Treatment Options Are Available?

Nonsurgical Treatment

Doctors closely monitor patients with symptoms from a thoracic disc herniation, even when the size of the herniation is small. If the disc starts to put pressure on the spinal cord or on the blood vessels going to the spinal cord, severe neurological symptoms can develop rapidly. In these cases, surgery is needed right away. However, unless your condition is affecting the spinal cord or is rapidly getting worse, most doctors will begin with nonsurgical treatment.

At first, your doctor may recommend immobilizing your back. Keeping the back still for a short time can calm inflammation and pain. This might include one to two days of bed rest, since lying on your back can take pressure off sore discs and nerves. However, most doctors advise against strict bed rest and prefer their patients do ordinary activities, using pain to gauge how much activity is too much. Another option for immobilizing the back is a back support brace worn for up to one week.

Doctors prescribe certain types of medication for patients with thoracic disc herniation. Patients may be prescribed anti-inflammatory medications such as aspirin or ibuprofen. Muscle relaxants may be prescribed if the back muscles are in spasm. Pain that spreads into the arms or legs is sometimes relieved with oral steroids taken in tapering dosages.

Your doctor will probably have a physical therapist direct your rehabilitation program. Therapy treatments focus on relieving pain, improving back movement, and fostering healthy posture. A therapist can design a rehabilitation program for your condition that helps you prevent future problems.

Most people with a herniated thoracic disc get better without surgery. Doctors usually have their patients try nonoperative treatment for at least six weeks before considering surgery.

Surgical Treatment

Laminotomy And Discectomy
The traditional way of surgically treating a herniated thoracic disc used to be to perform laminotomy and discectomy. The term laminotomy means "make an opening in the lamina", and the term discectomy means "remove the disc." The purpose of taking out a herniated thoracic disc was to decompress the spinal cord or spinal nerves. But nerve problems that occurred with this traditional method of decompression have led many doctors to discontinue this form of surgery for disc herniations in the thoracic spine.

Transthoracic Decompression
A new way to decompress the spinal cord or spinal nerves is a technique called transthoracic decompression. Operating from the patient's side, the doctor makes a small opening through the ribs and works on the spine through the chest cavity. A minimal amount of the vertebral body and problem disc are removed, taking pressure off the spinal cord. Fusion surgery is sometimes needed right afterward if a larger section of the vertebra has to be taken out.

Costotransversectomy
Pressure on the spinal cord from a herniated thoracic disc can also be effectively treated using a surgical procedure called costotransversectomy. The surgeon makes an incision through the back of the spine. The ends of one or more nearby ribs are removed where they join the spine. A section of the transverse process (the small bone on the side of the vertebra) is taken off. This forms an opening for the doctor to see the injured disc. The surgeon can then decompress the spinal cord by locating and removing the disc material that has ruptured into the spinal canal.

Video Assisted Thoracoscopy Surgery (VATS)
VATS is a new way to perform thoracic surgery. Only small incisions are required. The thoracoscope is a small T V camera that is passed through the chest cavity. Watching on a TV screen, the surgeon can see and treat the herniated disc. Because the incisions are small, most patients have an easier time recovering from the procedure.

Fusion
Fusion surgery joins two or more bones into one solid bone. The medical term for this procedure is arthrodesis. If surgery on the herniated thoracic disc requires removal of a large section of bone and disc material, the section of spine may become loose or unstable. When this happens it may be necessary to fuse the bones right above and below the unstable section. Bone graft material is used to get the unstable bones to grow together. Rods, plates, and screws are commonly used to hold the bones in place so the bone graft heals. Learn more about spinal fusion.

Complications

Like all surgical procedures, operations on the back may have complications. Because the surgeon is operating around the spinal cord, back operations are always considered extremely delicate and potentially dangerous. Take time to review the risks associated with thoracic spine surgery with your doctor. Make sure you are comfortable with both the risks and the benefits of the procedure planned for your treatment. Learn more about possible complications of spine surgery. There are also possible complications specifically related to a thoracic disc herniation.

After Surgery

Rehabilitation after surgery is more complex. Some patients leave the hospital shortly after surgery. However, some surgeries require patients to stay in the hospital for a few days. Patients who stay in the hospital may be visited by a physical therapist soon after surgery. The treatment sessions help patients learn to move and do routine activities without putting extra strain on the back.

During recovery from surgery, patients should follow their surgeon's instructions about wearing a back brace or support belt. They should be cautious about overdoing activities in the first few weeks after surgery.

Many surgical patients need physical therapy outside of the hospital. They see a therapist for one to three months, depending on the type of surgery. At first, therapists may use treatments such as heat or ice, electrical stimulation, massage, and ultrasound to calm pain and muscle spasm. Then they teach patients how to move safely with the least strain on the healing back.

As patients recover, they gradually begin doing flexibility exercises for the hips and shoulders. Mobility exercises are also started for the back. Strengthening exercises address the back muscles. Patients may work with the therapist in a pool. Patients progress with exercises to improve endurance, muscle strength, and body alignment.

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