Anatomy & Background
Spinal Nerves and Intervetebral Foramen
The thoracic spine is composed of 12 vertebral levels T1-T12. In the spine, there are areas where the intervertebral disc and facet joints, join two cervical vertebral bodies. Where this occurs, it forms two canals on either side of the spine. These canals are called intervertebral foramina. At each level, the cervical spinal nerves exit the spinal cord through the intervertebral foramen. The spinal nerves are the electrical wires of the body. The size or diameter of the spinal foramina varies from person to person. Any compromise or encroachment of the canal may put pressure on the exiting nerve producing symptoms varying from pain, tingling, numbness or even weakness.
Degeneration of the thoracic spine can manifest in different ways, from disc degeneration to bony spur or osteophyte formation resulting in possible nerve encroachment or pinching.
In general there is less movement in the thoracic spine. As a result the frequency of a thoracic radiculopathy is much lower than the thoracic and cervical spine.
Thoracic radiculopathy is the pain and resulting symptoms associated with compression on the nerve or nerve roots of the thoracic spine. When the symptoms radiate or refer distally from the spine into the back and outward along the ribs to the anterior chest wall it is considered radiculopathy.
Nerve Root Entrapment
A nerve root is the initial segment of a nerve where it leaves the central nervous system. Nerves that exit the area of the thoracic spine provide sensation and motor control to the back, trunk, chest, arms and internal organs. Damage or interference with the transfer of information of these nerves can cause neurological problems such as pain, weakness, abnormal sensations, and numbness. Entrapment is the compression or irritation of the nerve, or the nerve root.
Causes of Thoracic Radiculopathy
Anything that encroaches on, or presses on a nerve, and disrupts its function at the nerve root can be considered a cause of nerve root entrapment.
- Degenerative disc disease that results in wear on the intervertebral disc, and a reduction in disc height may result in loss of space at the intervertebral foramen.
- Herniated discs can place pressure on the nerve in addition to inflammation that irritates the nerve.
- Degenerative joint disease that results in the formation of bony spurs on the facet joints can narrow the intervertebral space placing pressure on the exiting nerve.
- Trauma or muscle spasm can put pressure on the peripheral nerve, producing symptoms along that nerve’s distribution path.
The symptoms experienced as a result of thoracic radiculopathy will be located along the same path that the nerve travels.
- Pain that starts in the lower neck and travels to the posterior shoulder, back and chest.
- Numbness or tingling may be experienced from the neck to the posterior shoulder, back and thorax or chest.
- Muscle weakness may occur on any muscle that is innervated by the pinched nerve. Long term pressure on the nerve can atrophy that muscle.
- Pain and tenderness that is localized at the level of the involved nerve.
- Muscle spasms and changes in posture in response to the injury.
- Loss of motion like the inability to bend backward, move sideways to the effected side, or turn the trunk.
- A poor tolerance for sitting.
- Pain experienced with excess activity and relief with rest.
Treatment of Thoracic Nerve Root Entrapment
Treatment of nerve root entrapment 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 medication.
- 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.
- An exercise regiment designed specifically to address the cause of the symptoms associated with pinched nerve and improve joint mobility, spinal alignment, posture, and range of motion.
- Steroidal medication to reduce inflammation in moderate to severe conditions.
- Thoracic nerve or epidural injections
- Physical therapy to reduce inflammation, restore joint function, improve motion, and help the return of full function.
In mild cases many patients found that rest, ice and medication were enough to reduce the pain. Physical therapy is recommended to develop a series of postural, stretching and strengthening exercises to prevent re-occurrence of the injury. Return to activity should be gradual to prevent a return 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 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.
Medications to consider
Your physician may recommend several medication options to reduce the pain, the inflammation and muscle spasms that may be associated with nerve root entrapment.
- Over the counter medications for mild to moderate pain.
- If over the counter medications are not effective, your physician may prescribe stronger pain medication.
- Anti-inflammatory drugs or prescription NSAIDS (non-steroidal anti-inflammatory drugs) to reduce inflammation following acute injury.
- Muscle relaxers to reduce acute muscle spasm.
- 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 Conditions
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 irritation that gets worse
- Weakness associated with muscle atrophy
- Associated disc involvement
Injections like facet injections, nerve blocks or an epidural. These may involve the injection of corticosteroids to a specific structure to reduce local inflammation caused that is irritating the nerve as it exits the foramen.
- Caudal Epidural Injections
- Interlaminar Caudal Epidural Steroid Injections
- Transforaminal Epidural Injections
- Selective Nerve Root Blocks
Surgical Procedures to address the structures that contribute to the compression on the nerve as it exits the intervertebral foramen.
- Endoscopic Decompression
- Endoscopic Foraminotomy
- Percutaneous Decompression
- IDET Intradiscal Eletrothermal Therapy
- Selective Endoscopic Discectomy
- Spinal Cord Stimulator
- Epidural Lysis of Adhesions
- Laser Facet Arthrotomy