Thoracic Disc Syndrome

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 prolapse” 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.[1]
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.[1]
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.[1],[2]
It most often affects the lower thoracic spine, between T9 and T12, because of the greater mobility of these vertebrae.[3]
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. [3]
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.[4] 
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.[4]
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.[4]
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.[4]




Epidemiology/Etiology

Thoracic disc herniation is a rare event. Of all the herniated discs, less than 1% occur in the thoracic region. [4][5]  According to another study by M. Scott Linscott, 4-5% of all disc herniations happen in the thoracic region. [6]  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. [3]  The peak age for thoracic disc herniation is 40-50 years, more frequently in men (Arseni & Nash 1960). [2] More than 70% of the thoracic disc herniations are asymptomatic.  [5]
Thoracic disc lesions are primarily degenerative and affects mostly the lower part of the thoracic spine. [2]  
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.  [6]
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. [6]


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. [3]
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. [3]


Characteristics/Clinical Presentation

Most of the time the thoracic disc disorders are located in the mid back at the thoracolumbar junction (T8-T12). [5]  Mostly these disc disorders do not cause any symptoms because the disc is almost completely without nociceptive structures.  [5]
If, nevertheless, symptoms are extant, pain is the most common. [1]  The pain can be located in the upper back or radiated in a dermatomal pattern. [1] The pain can be exacerbated when sneezing or coughing. [7]
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. [3]
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. [2][5] 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. [5]
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. [8]
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. [8][9][1][5]
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. [1][3][5]
Other rather uncommon symptoms are bladder symptoms such as incontinence. [9][1][2][5]
Most of the thoracic disc herniations are asymptomatic. The most common complaint of these patients is radicular chest pain. [5]



Differential Diagnosis

Thoracic disc herniations are commonly misdiagnosed as cardiac disorders, abdominal problems, gastrointestinal, neoplastic and demyelinating diseases, tumours, ankylosing spondylitis and intercostal neuralgia.[1][2]([5]

- 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.[8]

- 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.[6]

- Lumbosacral disc injuries: Collective name for injuries of lumbosacral discs.[10],[6],[8],[9],[1],[2])

- 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.[10]

- 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 [4],[5],[7])

- Lumbosacral Spondylolisthesis:Spondylolisthesis is defined as forward translation of a vertebral body with respect to the vertebra below [10],[6][8],[9],[1],[2])
-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.[3]

Diagnostic Procedures

The use of CT in combination with myelography and MRI greatly increased the ability to accurately visualize thoracic spine disorders. [2]
A myelogram usually indicates the level of the lesion with certainty, although, special projections may be needed. [8]
Today, MRI is the imaging method of choice in the investigation of the thoracic spinal canal. [9]
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.

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. [1]
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. [5]



Examination

To examine whether the patient has thoracic disc syndrome, we have to investigate several items such as reflexes, dermatomes, sensory changes, etc. [8][9][1]
The cervical, thoracic and lumbar spine should be evaluated as well as the abdominal and hip musculature. These tests can reveal weakness, inflexibility and/or myofascial pain which can be related at thoracic discogenic syndrome.
Also the muscle strength and tone should be tested. Because a lesion at T9 and/or T10 can cause paralysis of the lower abdominal muscles while the upper abdominal muscles preserve their strength, a strength test of these muscles is necessary. The lesion can cause a Beevor sign which means that the umbilicus makes an upward movement when the abdominal wall contracts. Observing if the movement of the rectus abdominis is asymmetric can also be helpful.
The lower extremities should also be tested. If there is weakness associated with hyperactive reflexes or spasticity, myelopathy is indicated. [8]
Another item that should be tested are the reflexes, more specific the abdominal reflexes and the cremasteric reflex in male patients. The abdominal reflex can be provoked by stimulating the skin overlying the abdominals. The underlying muscles normally contract. The cremasteric reflex can be provoked by stroking the skin on the medial side of the thigh next to the scrotum. Normally the tested on the provoked side will be pulled superiorly. [7]
The upper extremity reflexes should be normal as well as the patellar and Achilles reflexes in case of purely discogenic pain or thoracic radiculopathy. If the patient has hyperactive patellar and/or Achilles reflexes or clonus, cord compression and myelopathy is indicated.
If the patient has a thoracic disc herniation, sensory symptoms can be present. It can cause altered sensation to light touch or pinprick along a dermatomal pattern. Cord compression and myelopathy should be strongly considered if a sensory level is established such that sensation is consistently altered below a specific dermatome. [7]
Provocative maneuvers such as the spurling maneuver (cervical radiculopathy) and the straight-leg raise test or the slump test (lumbosacral radiculopathy) may exclude a thoracic disc syndrome. Neck flexion can provoke symptoms due to thoracic disc protrusion.
Further research is necessary. [8][9] ( [1]



Medical Management

Most patients with symptomatic thoracic disc disease will respond favourably to non-operative management.
If there is no surgery performed, a short period of rest is recommended (one or two days). After this short period, the patient should resume his activities. The patient can take pain medications. If the pain is severe, narcotic pain medication can be described for a short period. Also anti-inflammatory agents (NSAID’s) can be described to help reduce inflammation around the herniated disc.
If the patient has severe pain, epidural steroid injection (ESI) can become an option. 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).
Only 5% of all disc herniations are symptomatic thoracic disc herniations. From this number we can conclude that it is an uncommon problem. Till today there is little know about the natural history of this disease which makes the indications for surgery unclear. Even though, severe and progressive myelopathy are considered as absolute indications for surgery. [9]
Earlier, the number one approach to treat thoracic disc herniations non-conservatively, was laminectomy. The outcomes of this surgery method were disappointing because of high complication rates and unsatisfactory operative results. Nowadays is this technique not in use anymore. [9]
Since then there have been newer approaches developed to treat thoracic disc herniations, such as: the transpedicular approach and the transfacet pedicle-sparing approach. These two methods of operation are relatively safe, especially when the disc herniation is situated laterally.
However, when a disc is herniated centrally, these techniques can cause high complication rates, mainly because the spinal cord has to be mechanically manipulated to guarantee visibility during the surgery. This process can produce direct mechanical injury to the spinal cord and it can possibly interfere with the blood supply of the cord. [9]
For the treatment of patients with central thoracic disc herniation, there have been safer and more suitable approaches developed, such as costotransversectomy, a lateral extracavitary (posterolateral approach) or a classic transthoracic (anterolateral) approach.
These techniques make sure there is direct access and visibility to the disc during the operation. Disadvantages can be the more extensive nature of these approaches and in the case of transthoracic techniques there can be a chance of developing pulmonary and mediastinal complications. To avoid these complications, thoracoscopic techniques have been invented, which minimize the invasive nature of the proces. The only downside of this process is that the learning curve to acquire sufficient experience in the practice of these techniques is very long and it is not easy to achieve because of the small number of patients with symptomatic thoracic disc herniation. [9]
From the study of Coppes Et.al we can conclude that the posterior transdural approach to treat symptomatic thoracic disc herniation seems like a promising procedure to remove centrally herniated thoracic intervertebral discs. [9]


Physical Therapy Management

Because Individuals with congenital or developmental deformities of the spine such as scoliosis or kyphosis may be more likely to develop thoracic disc degeneration, exercise therapy in improving postural hyperkyphosis is recommended.  [3]

The intervention should be a multimodal, kyphosis specific exercise program. It should target multiple musculoskeletal impairments known to be associated with hyperkyphosis, including spinal extensor muscle weakness, decreased spinal mobility, and poor postural alignment.[1]

This Physical therapy should than involve:

  • Hyperextension strengthening [2]; [1] [4]
  • Postural training [2] ; [1]
  • Body mechanics education [2]
  • McKenzie technique  [3]
  • Maitland technique [3]
  • Stretching of the M. Pectoralis Major ([4])
  • Mobilisation [4]
  • Massage [3]
  • Passive mobilisation [4]

Hyperextension strengthening
Training of the muscles used for hyperextention. This is done to prevent the hyperkyphosis, most patients with thoracic disc problems are in a position of hyperkyphosis. This is a big problem especially in the 21th century, because of the portables and tablets. which is the cause of most thoracic disc problems.

Strengthening of the thoracal extensor muscles can be achieved by following exercises:

Bow and arrow on the side [1]

With this exercise it is important to give the following instructions:

  • The upper back and abdominal muscles should be working at all times.
  • The legs should not be moving and should be in a 90° angle in the hip and in the knee to make sure that the pelvis stays in position.

Foto 6: bow and arrow exercise nicksportphysio.com

Pointer dog [1]

  • With this exercise it is important to give the following instructions:
  • The upper back and abdominal muscles should be working at all times as well as the pelvic floor.
  • Don’t raise your leg and arms to high (max horizontal)

Foto 7: 3 Bird-Dog Exercise Variations www.builtlean.com

Superman[1]

  • With this exercise it is important to give the following instructions:
  • The upper back and abdominal muscles should be working at all times
  • Start with lifting your legs slightly of the floor than lift your torso of the floor

Foto 8: (Katzman WB, Vittinghoff E, Kado DM, Schafer AL, Wong SS, Gladin A, Lane NE.
Study of Hyperkyphosis, Exercise and Function (SHEAF) Protocol of a Randomized
Controlled Trial of Multimodal Spine-Strengthening Exercise in Older Adults With
Hyperkyphosis. Phys Ther. 2016 Mar;96(3):371-81 - LoE 1B)



Occiput to wall [4]


Stretching the Extensor Muscles and strengthening the Anterior Neck Flexors: The patient stands with his back against the wall and retracts the chin. There will be an upper cervical spine flexion and lower cervical spine extension. Hold this position for 15 seconds. [4]



Postural training
The training of all the postural muscles is important to assure the stability of the spine, the muscles should be trained for long periods of time to simulate the use in the daily life activities such as standing for a long period of time. ([5] [1])

Training of the postural muscles can be achieved by following exercise:
Single leg stance [1]
With this exercise it is important to give the following instructions:

  • The upper back and abdominal muscles should be working at all times as well as the pelvic floor.
  • Roll shoulder blades backwards

“Lengthen” your neck
Don’t raise your leg to high (+- 10cm of the floor)
Foto 9: ( Katzman WB, Vittinghoff E, Kado DM, Schafer AL, Wong SS, Gladin A, Lane NE.
Study of Hyperkyphosis, Exercise and Function (SHEAF) Protocol of a Randomized
Controlled Trial of Multimodal Spine-Strengthening Exercise in Older Adults With
Hyperkyphosis. Phys Ther. 2016 Mar;96(3):371-81 - LoE 1B)

Body mechanics education
It is is important that the patiënt understands his problem and the cause of his problem. In the particular case of thoracic disc herniation it is important that the patiënt realises that being in a position of hyperkyphosis will increase his symptoms. [5]
Foto 3 (41) Encyclopedia of Sportsmedicine p257 Lyle J., Micheli M.D. (LoE: 5)
https://www.ugbodybuilding.com/threads/3572-Lumbar-Disc-Herniation
Disk bulging, difference between the bend forward position and the bend backward position. (This is a photo of what goes on in the lumbar spine but the same occurs in the thoracic spine) [5]

McKenzie technique
This technique is used to re centralise the bulging disc. But also to ‘centralise’ complaints from peripheral (first days) to thoracic region (after 10 days) [3]

Foto 4 (42) Athletic Training and Sports Medicine; Schrijver: Robert C. Schenck; Editor: Jones & Bartlett Learning, 1999 (LoE: 5)

Maitland technique
The maitland technique uses specific methods of oscillation or sustained holds to eliminate reproducible signs of pain. [3]
Foto 5 [3]
Athletic Training and Sports Medicine; Schrijver: Robert C. Schenck; Editor: Jones & Bartlett Learning, 1999 (LoE: 5)


Stretching M. pectoralis major and M. latissimus dorsi
Manual therapy and exercise therapy program improving postural hyperkyphosis:
Stretching the Pectoralis Major Muscle: While facing a corner, the patient places his hands on the wall at shoulder level. Than the patient moves forward, closer to the wall, to stretch the anterior chest. Hold this position for 15 seconds. [4]

Stretching the Latissimus Dorsi Muscle: Patient lay in supine position with knees and hips flexed. Arms are in 90-90 position. Then the patient performs a posterior pelvic tilt while raising the arms overhead as far as possible without losing floor contact. Hold this position for 15 seconds. [3]


Massage
Massage: wringing and skin rolling massage to the back extensor muscles for 10 minutes

Passive mobilisation
Apply downward pressure toward thoracic extension. [3]



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.

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3. ↑ 3.0 3.1 3.2 3.3 http://www.mdguidelines.com/degeneration-thoracic-or-thoracolumbar-intervertebral-disc
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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.
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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

The term ‘thoracic syndrome’ refers to all pathological clinical manifestations due to functional (physiopathological) disturbances and degenerative changes of the thoracic motion segments.[1] Due to the rarity of this subject, little importance is attached to it in the literature. [5]
Several articles suggest an incidence between 0.2% and 5.0% of all intervertebral disc herniations. It should also be more common in men. [2]
Mostly these disc disorders do not cause any symptoms. If, nevertheless, symptoms are extant, pain is the most common.(25) Other symptoms are sensory disturbances, referred pain, weakness in the abdominal and intercostal muscles, paresthesias, weakness of the lower extremities and bladder symptoms. [8][9]([1][2]([5]
One of the main problems in the treatment of thoracic disc herniation has been the lack of accuracy of diagnostic tests. Disc herniation can be revealed by MRI but there aren’t really specific physical test to include this disease. Literature show that musculoskeletal, reflexes, sensory aspects, strength and provocative maneuvers should be tested.([8][9][1]
From medical research we can conclude, based on the study of Coppes. et.al , that the posterior transdural approach seems like a promising procedure to remove centrally herniated discs in patients with symptomatic throacic disc herniation. [7]
Thoracic disc protrusions can be reduced by manipulation in 3 to 5 sessions.
Physical therapy should involve hyperextension strengthening [9], postural training [9] body mechanics education [9], McKenzie technique [2] and Maitland technique [2].


Recent Related Research

Case Studies
In the case study of Bin Yue et.al they present two adult patients with thoracic intervertebral disc calcification and herniation. The purpose of this study was to report two cases of patients with acute paraplegia caused by a calcified thoracic disc prolapse and to discuss the clinical diagnosis and surgical treatment of this problem. [10]
Case 1
In the first case, the patient was a woman, 57-years old with back pain already for 40 days. She experienced numbness in her lower extremity, bilateral and weakness for 20 days, bowel or bladder incontinence for 5 days. The findings of physical examination were: a lesser sensation below T11 level, bilateral lower extremity paraplegia with muscle force level zero, diffuse hyperreflexia(patellar jerk and Achilles tendon reflex for +++) and positive Babinski signs. CT imaging showed calcification of the nucleus pulposus with posterior central herniation within the disc space at level T11-T12. MRI showed a serious level of compression of the spinal cord at the disc of the segment T11-T12. After the diagnosis: calcified thoracic intervertebral disc with herniation, the patient underwent discectomy done with a posterior transfacet approach, which was followed by interbody fusion with instrumentation. The surgeon removed the calcified parts of the disc.


The results of the pathological examination of the removed parts was: degenerative fibrocartilage and calcium deposition. After a 2-year follow-up the patient did not show any important functional change in the postoperative period (such as muscle force, hyperreflexia, Babinksi signs). [10]
Case 2
The second patient of this study was a 53-year old man with back pain for 2 months, paraplegia of the lower extremity bilateral and bowel or bladder incontinence for 15 days. The main complaint of the patient was back pain. The findings of physical examination were: paresis of the lower extremity bilateral below the level T10, paraplegia of the lower extremity bilateral with muscle force level zero and diffuse hyperreflexia(patellar jerk and Achilles tendon reflex for +++) with positive Babinski signs. CT imaging showed some high-density mass at the disc of the level T10-T11. MRI results showed a serious degree of spinal cord compression with a hyperintense central core and surrounding hypointense area at the intervertebral disc at level T10-T11. These findings led to the diagnosis: intervertebral disc calcification and protrusion. The surgical method of getting rid of the calcification was in this case also disectomy, through transversoarthropediculecttomy via bilateral posterolateral approach and interbody fusion with instrumentation. The researchers have found similar results as they have found in case 1: calcium deposition in the disc which was like ‘semisolid toothpaste’. This patient was followed-up 6 months and they have established full recovery (sensation, muscle force, hyperreflexia, and Babinski signs). [10]
Researchers of this study found that if decompression surgery would not have been performed, spinal cord compression would have progressed further in these two patients which would have inevitably caused spinal cord injury. The research team therefore suggests to carry out decompression surgery as soon as possible for patients with early spinal myelopathy or paraplegia caused by a calcified protruded disc. [10]

  1. 1.00 1.01 1.02 1.03 1.04 1.05 1.06 1.07 1.08 1.09 1.10 1.11 1.12 1.13 1.14 1.15 1.16 1.17 1.18 1.19 1.20 1.21 1.22 1.23 1.24 Juergen Kraemer, 2009, Intervertebral Disk Diseases: Causes, Diagnosis, Treatment and Prophylaxis , Thieme , Stuttgart, 375p. (LoE 5)
  2. 2.00 2.01 2.02 2.03 2.04 2.05 2.06 2.07 2.08 2.09 2.10 2.11 2.12 2.13 2.14 2.15 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. 3.00 3.01 3.02 3.03 3.04 3.05 3.06 3.07 3.08 3.09 3.10 3.11 3.12 3.13 3.14 3.15 3.16 http://www.mdguidelines.com/degeneration-thoracic-or-thoracolumbar-intervertebral-disc
  4. 4.00 4.01 4.02 4.03 4.04 4.05 4.06 4.07 4.08 4.09 4.10 4.11 4.12 Justin G. R. Fletcher et.al; CT morphometry of adult thoracic intervertebral discs; European Spine Journal; 2015; 24: 2321-2329; LoE: 5
  5. 5.00 5.01 5.02 5.03 5.04 5.05 5.06 5.07 5.08 5.09 5.10 5.11 5.12 5.13 5.14 5.15 5.16 5.17 Ozturk C, et all. Far lateral thoracic disc herniation presenting with flank pain. The Spine Journal. 2006;6:201-203 LoE 3B
  6. 6.0 6.1 6.2 6.3 6.4 6.5 M. Scott Linscott et.al; Thoracic Intervertebral Disk Herniation: A commonly missed diagnosis; Journal of emergency medicine; vol 32; No. 3; pp. 235-238, 2007 LoE: 2B
  7. 7.0 7.1 7.2 7.3 7.4 Malanga G, et all. Thoracic Discogenic Pain Syndrome. [1] recieved 1 may 2016
  8. 8.00 8.01 8.02 8.03 8.04 8.05 8.06 8.07 8.08 8.09 8.10 Whitmore R.G, et all. A patient with thoracic intradural disc herniation. Journal of Clinical Neuroscience 18. 2011:1730-1732 LoE:3B
  9. 9.00 9.01 9.02 9.03 9.04 9.05 9.06 9.07 9.08 9.09 9.10 9.11 9.12 9.13 9.14 9.15 9.16 20 Deitch K, et all. T2-3 Thoracic disc herniation with myelopathy. The journal of Emergency Medicine.2009;36(2):138-140 LoE 3B
  10. 10.0 10.1 10.2 10.3 10.4 10.5 10.6 27 Kalichman L, Hunter DJ. Diagnosis and conservative management of degenerative lumbar spondylolisthesis. Eur Spine J. 2008 Mar. 17(3):327-35. . LoE: 1B