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Thoracic Disc Herniation

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Topic updated on 12/26/14 4:36pm
Introduction
  • Relatively uncommon and makes up only 1% of all HNP.
  • Epidemiology
    • demographics
      • most commonly seen between 4th and 6th decades of life
        • as the disc desiccates it is less likely to actually herniate
    • location
      • usually involves middle to lower levels
      • T11-T12 most common level
      • 75% of all thoracic disc herniations occur between T8 and T12
    • risk factors
      • underlying Scheuermann's disease may predispose to thoracic HNP
Classification
  • Herniation type
    • bulging nucleus
      • annulus remain intact
    • extruded disc
      • through annulus but confined by PLL
    • sequestered
      • disc material free in canal
  • Location classification
    • central
    • posterolateral
    • lateral
Presentation
  • Symptoms
    • pain
      • axial back or chest pain is most common symptom
      • thoracic radicular pain
        • band-like chest or abdominal pain along course of intercostal nerve
      • arm pain (see with HNP at T2 to T5)
    • neurologic
      • numbness, paresthesias, sensory changes
      • myelopathy
      • paraparesis
      • bowel or bladder changes (15% - 20% of patients)
      • sexual dysfunction
  • Physical exam
    • localized tenderness
    • root symptoms
      • dermatomal sensory changes (paresthesias and dysesthesia)
    • cord compression and findings of myelopathy
      • weakness
        • weakness or mild paraparesis
        • abnormal rectal tone
      • upper motor neuron findings
        • hyperreflexia
        • sustained clonus
        • positive Babinski sign
      • gait changes
        • wide based spastic gait
    • Horner's syndrome
      • seen with HNP at T2 to T5
Imaging
  • Radiographs
    • lateral radiographs
      • may show disc narrowing
      • may show calcification (osteophytes)
  • MRI
    • most useful and important imaging method to demonstrate thoracic disc herniation
      • allows for identification of neoplastic pathology
      • can see intradural pathology
      • will show myelomalacia
      • may not fully demonstrate calcified component of herniated disc
    • disadvantage is high false positive rate
      • in a study looking at asymptomatic individuals 
        • 73% had thoracic disk abnormalities 
        • 37% hand frank herniations
        • 29% of these had cord compression.
Treatment
  • Nonoperative
    • activity modification, physical therapy, and symptomatic treatment 
      • indications
        • the majority of cases
      • modalities include
        • immobilization and short term rest
        • analgesic
        • progressive activity restoration
        • injections may be useful for symptoms of radiculopathy
      • outcomes
        • majority improve with nonoperative treatment
  • Operative
    • discectomy with possible hemicorpectomy or fusion 
      • indications
        • surgery indicated in minority of patients
        • acute disc herniation with myelopathic findings attributable to the lesion, especially if there is progressive neurologic deterioration
        • persistent and intolerable pain
      • technique
        • debate between discectomy with or without fusion is controversial.
          • most studies do indicate that anterior or lateral (via costotransversectomy) is the best approach
        • see below for different approaches
Surgical Techniques
  • Transthoracic discectomy
    • indications
      • best approach from central disc herniations
    • complications
      • intercostal neuralgia q 
    • techniques
      • can be done with video assisted thoracic surgery (VATS)
  • Costotransversectomy
    • indications
      • lateral disc herniation
      • extruded or sequestered disc

 

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Qbank (5 Questions)

TAG
(OBQ09.190) A 29-year-old male presents with numbness and tingling in his lower extremities and gait instability for two weeks duration. Physical exam shows 3+ brisk patellar reflexes. Magnetic-resonance-imaging is shown in Figure A. What is the most appropriate first line of treatment? Topic Review Topic
FIGURES: A          

1. Observation
2. Physical therapy
3. Epidural injection
4. Laminectomy
5. Anterior diskectomy

PREFERRED RESPONSE ▶
TAG
(OBQ07.131) A 47-year-old male presents with back pain of 2 weeks duration. He denies night sweats, fevers, or weight loss. He localizes his symptoms to a dermatomal distribution along the rib cage on the right. On physical exam he has mild paraspinal tenderness, normal patellar reflexes, normal muscle strength in his lower extremities, and a normal gait exam. An MRI is shown in Figure A and B. What is the most appropriate first step in management? Topic Review Topic
FIGURES: A   B        

1. A repeat MRI with gadolinium
2. CT of chest, abdomen, and pelvis followed by a CT guided biopsy of the spinal lesion
3. Physical therapy and NSAIDs
4. Surgical decompression using a midline posterior approach
5. Surgical decompression using a transthoracic approach

PREFERRED RESPONSE ▶
TAG
(OBQ06.168) A 55-year-old woman undergoes endoscopic transthoracic anterior surgery for a herniated disk in the thorax. What is the most likely complication following surgery? Topic Review Topic

1. Increased kyphosis
2. Pseudarthrosis
3. Intercostal neuralgia
4. Pneumothorax
5. Cardiac tamponade

PREFERRED RESPONSE ▶



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