Anatomy & Background


Intervertebral Disc

Between each vertebra lies a fibrocartilagenous structure called the intervertebral disc. This disc is present at all levels of the thoracic spine. The disc is comprised of a series of outer fibrous rings (annulus fibrosis) and a softer center (nucleus pulposus). The walls of the disc are thinnest and weakest posterior laterally where the spinal nerves exit the spinal column. The disc serves as a joint between the vertebrae, functions as a cushion and allows movement between the vertebra.

Degenerative Disc Disease

Degenerative Disc disease is a term to describe the progressive, gradual wear and tear of the intervertebral disc. This degeneration affects the outer annulus fibrosis and nucleus pulposus. As the disc wearsthere is loss of disc height and increased likelihood of the development of bulging and herniated discs. Degeneration of the disc is normal with aging but can be accelerated as a result of trauma, repetitive strain or injury as well as musculo-skeletal imbalances like scoliosis. Disc degeneration itself may not be a problem, but the associated conditions that may develop as it progresses can be symptomatic and debilitating.

Inflammation, damage or degeneration of a disc can cause a range of symptoms that vary based on the severity of the problem. Disc pathology may produce a loss of back motion, back pain, pain that may radiate from the back around the ribs and chest, numbness, tingling, muscle spasm or some combination of these symptoms. The most common area of thoracic disc problems occurs between T8-T12. Thoracic disc degeneration occurs far less than in the lumbar and cervical areas because the thoracic spine is less mobile than these other areas of the spine.

Common conditions of the intervertebral disc include bulging disc, herniated disc, prolapsed disc, degenerative disc disease, anular tear of the disc, ruptured disc and slipped disc.

Stages of Disc Degeneration


The progression of disc degeneration can be classified in the following phases:

1. Dysfunction

  • The annular rings of the disc tear and the irritation of the facet joints at the corresponding spinal level may occur.
  • There is loss of joint mobility, localized back pain, muscle spasm, and loss of movement especially extension or backward motions.

2. Instability

  • Loss of disc fluid with dehydration and disc narrowing. The facet joints and capsule may develop laxity resulting in instability.
  • A patient will present with pain, sharp catching, giving way, a shift in spinal alignment and loss of motion.

3. Restabilization

  • The body reacts to the instability by laying down bone in the form of osteophytes to stabilize the spine. This increase in bone formation can result in Stenosis.
  • Back pain will usually decrease, but remain present in a less severe form. Individuals may develop stenotic-like symptoms.

Causes


  • Aging is the most common cause of disc degeneration. As the body ages the discs start to lose fluid and dehydrate. The discs start to narrow and lose their height, compromising their ability to absorb shock and stress.
  • The outer fibrous annular rings may begin to crack and tear, weakening the disc walls.
  • Individuals who smoke, are obese, or are involved in activities that require heavy labor are more likely to develop disc degeneration.
  • A sudden fall or trauma to the spine or disc may begin the degenerative process.
  • A disc herniation may initiate the stages of disc degeneration.
  • Unlike muscles, there is minimal blood supply to the discs, so they lack the ability to repair themselves.

Symptoms


The symptoms associated with degenerative disc disease of the thoracic spine will depend on the location and structures that are affected. Thoracic disc degeneration can affect the back, shoulder blades, and run along the distribution of the ribs.

  • Please Note: Many patients with DDD (degenerative disc disease) do not exhibit symptoms.
  • Chronic thoracic pain with or without radiation to the chest wall or ribs
  • Sensory changes such as numbness or tingling if the nerve is compromised.
  • Muscle spasms and changes in posture in the thoracic area.
  • Loss of motion with decreased ability to move the trunk when performing motions like turning, backward bending, and side bending.
  • Sitting for extended periods of time may produce back and arm pain.
  • Difficulty with lifting and over the head activities.
  • In later stages spinal Stenosis may develop resulting in lower extremity weakness and loss of coordination. In these cases surgical intervention will be required.

Treating Degenerative Disc Disease


Treatment of thoracic degenerative joint disease or injury will depend on the severity of the condition. When treating acute back problems:

  • Rest. Avoid the activities that produce the pain (bending, lifting, twisting, turning, bending backwards, etc).
  • Anti-inflammatory drugs and other pain medications.
  • Apply ice in acute cases to the thoracic spine to help reduce pain and associated muscle spasm. Apply it right away and then at intervals for about 20 minutes at a time. Do not apply directly to the skin.
  • Moist heat may be helpful to reduce pain and improve any feelings of stiffness.
  • An exercise regiment designed specifically to address the cause of the symptoms associated with the degenerative disc disease and improve joint mobility, spinal alignment, posture, and range of motion.
  • The use of supports may be necessary to reduce stress on the facet joints, muscles and thoracic area of the spine.
  • Steroidal medication to reduce inflammation in moderate to severe conditions
  • Epidural  injections directly to the involved disc may be indicated
  • Physical therapy to reduce inflammation, restore joint function, improve motion, and help return full function.

Mild Cases


In mild cases patients often found that rest, ice and medication were enough to reduce the pain. Once the pain is reduced, physical therapy is recommended to develop a series of stretching and strengthening exercises to prevent re-occurrence of the injury. Return to activity should be gradual to prevent a flare up of symptoms.

Moderate to Severe Cases


If the problem persists, consult with your health care provider. Your physician will perform a thorough evaluation to determine the possible cause of your symptoms, the structures involved, the severity of the condition, and the best course of treatment.

Medicine Intervenes


In addition to performing a thorough examination your physician may order the following tests to make a more concise diagnosis:

  • X-ray to determine if there is any joint degeneration, fractures, bony malformations, arthritis, tumors or infection present.
  • MRI to determine any soft tissue involvement including visualization of the discs, spinal cord and nerve roots.
  • CT scans, which can give a cross section view of the spinal structures.
  • EMG which is used to determine nerve involvement or damage.
  • Myelogram, which involves the injection of dye into the spinal column followed by an X-ray to visualize the position of, and the pressure being applied to, the discs or spinal cord.

Medications to consider


Your physician may recommend several medication options individually or in combination to reduce the pain, inflammation and muscle spasm that may be associated with disc injuries.

  • Over the counter medications for mild to moderate pain.
  • Narcotics, if over the counter medications are not effective your physician may prescribe stronger pain medication.
  • Anti-inflammatory drugs or prescription NSAIDS to reduce inflammation following acute injury.
  • Muscle relaxers to reduce acute muscle spasm.
  • Nerve pain medication by prescription, designed specifically to reduce pain from nerve damage.
  • Injections like facet injections, nerve blocks or an epidural. These may involve the injection of corticosteroids to a specific structure to reduce local inflammation.

Severe or Non-responsive Disc Conditions


The majority of thoracic disc herniations can be treated successfully without surgery. In the case of conditions that do not respond to conservative care, surgery may be indicated. If you continue to experience some of the following symptoms:

  • Increase in radiating or radicular pain
  • Pain or nerve damage that gets worse
  • The development of or an increase in weakness
  • Increase in numbness or parasthesia

Medical Procedures


Injections like facet injections, nerve blocks or an epidural. These may involve the injection of corticosteroids to a specific structure to reduce local inflammation.

  • Caudal Epidural Injections
  • Facet Joint Injections
  • Interlaminar Caudal Epidural Steroid Injections
  • Transforaminal Epidural Injections
  • Selective Nerve Root Blocks
  • Medial Branch Blocks

Surgical Procedures

  • Endoscopic Decompression
  • Endoscopic Foraminotomy
  • Percutaneous Decompression
  • IDET Intradiscal Eletrothermal Therapy
  • Selective Endoscopic Discectomy
  • Spinal Cord Stimulator
  • Radiofrequency Ablation
  • Epidural Lysis of Adhesions