Anatomy & Background
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 soft 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 vertebra, functions as a cushion and allows movement between the vertebra.
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 may radiate from the back around the ribs and chest, numbness, tingling, muscle spasm or some combination of several of these. The most common area of thoracic disc problems is between T8-T12. The incidence of thoracic disc problems is far less than in the lumbar and cervical area.
Common conditions of the intervetebral disc include bulging disc, herniated disc, prolapsed disc, degenerative disc disease, anular tear of the disc, ruptured disc and slipped disc.
A disc herniation occurs when the outer walls of the intervertebral disc (annulus fibrosis) tear. Other terms for this are “ruptured disc,” “prolapsed disc,” or “slipped disc.” When outer annular rings tear, the central gel like nucleus pulposus can push out pressing on the structures in the area. The herniation usually occurs at the posterior lateral wall where the annulus fibrosis is thinnest. Unfortunately this is where the nerves of the spine exit and track distally to the body. The larger the tear and the further the nucleus push out, the more severe the symptoms. Disc herniation can be caused by the following:
- Degeneration or general wear-and-tear which can break down the walls of the disc.
- Repetitive bending and twisting motions especially in combination. These motions place the most stress on the outer fibrous rings.
- Discs are most susceptible to injury in the sitting or bending position as the pressure on the disc is displaced to the front pushing the contents of the disc posterior laterally toward the thinner weaker annulus fibrosis.
- A sudden fall or trauma, like a motor vehicle accident, can result in a disc herniation.
- Genetic factors can contribute to the likelihood of intervertebral disc disease.
When a disc is herniated the symptoms will depend on the location of the herniation and what soft tissue structures it effects. Symptoms can vary from mild or none at all if the disc is the only structure involved or:
- Pain in the upper back or radicular to the chest and stomach area.
- Sensory Changes such as numbness or tingling if the nerve is compromised.
- Muscle spasms and changes in posture in response to the injury.
- Loss of motion inability to bend, stand erect or poor tolerance to sitting
- Sitting and bending can be difficult if the herniation is severe enough. Often times the patient will present in a shifted posture and have difficulty finding a comfortable position
- A patient with a herniation may be symptom free if the disc does not press on a sensitive soft tissue structure.
- If the disc is herniated into the spinal cord area it can result in sensory losses and weakness below the effected level along with balance issues.
Treating a Disc Herniation
Treatment of a disc herniation or injury will depend on the severity of the condition. When treating acute disc or back problems
- Rest. Avoid the activities that produce the pain (jumping, running, stairs, kneeling, squatting, etc).
- Anti-inflammatory drugs and other pain medications.
- Apply ice to the lumbar 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.
- An exercise regiment designed specifically to address the cause of the symptoms.
- The use of a brace or other support may be necessary to reduce stress on the disc, muscles and thoracic spine.
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 should 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.
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 and 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 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.
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 my prescribe stronger pain medication
- Anti-inflammatory 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 nerve damage pain
- Injections such as facet injections, nerve blocks or epidural injections. 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 is getting worse
- The development or increase in weakness
- Increase in numbness or parasthesia
- Loss of bowel and bladder control
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
- Interlaminar Caudal Epidural Steroid Injections
- Transforaminal Epidural Injections
- Selective Nerve Root Blocks
- Endoscopic Decompression
- Endoscopic Foraminotomy
- Percutaneous Decompression
- IDET Intradiscal Eletrothermal Therapy
- Selective Endoscopic Discectomy
- Spinal Cord Stimulator
- Epidural Lysis of Adhesions