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 gelatinous center (nucleus pulposus). The walls of the disc are thinnest and weakesr 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.
Inflammation, damage or degeneration of a disc can cause a range of symptoms, which vary based on the severity of the problem. Disc pathology may produce a loss of back motion, back pain, pain that radiates from the back around the ribs and chest, numbness, tingling, muscle spasm or some combination of these symptoms. The thoracic level with the highest rate of disc degeneration is T8-T12. The incidence of thoracic disc problems is far lower than in the lumbar and cervical area
A slipped disc is a misnomer, because the disc does not actually slip out of place between the vertebrae. Instead, a slipped disc occurs when the outer walls of the intervertebral disc are torn. Other terms for this condition are herniated disc, prolapsed disc, or ruptured disc. When outer annular rings are torn the central gel-like nucleus pulposus can push out and place pressure on the other structures in the area. The slipped disc 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 into the body. The larger the tear, and the further the nucleus pushes out into the surrounding area, the more severe the symptoms.
- Degeneration or general wear-and-tear, that breaks 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 (anteriorly) pushing the contents of the disc posterior laterally toward the thinner and weaker disc walls.
- A sudden fall or trauma, such as a motor vehicle accident.
- Genetic factors may contribute to the likelihood of intervertebral disc disease.
- Smokers are more susceptible to disc degeneration.
When a slipped disc occurs the symptoms will depend on the location of the slipped disc and which soft tissue structures are involved. Symptoms can vary from none at all to mild if the disc is the only structure involved, or can be more severe. Other symptoms can include:
- 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 spasm and changes in posture in response to the injury.
- Loss of motion, an inability to bend and stand erect or poor tolerance to sitting
- Sitting and bending can be difficult if the bulge is severe. Often the patient will present in a shifted posture and have difficulty finding a comfortable position.
- A patient with a bulge may be symptom free if the disc does not press on a sensitive soft tissue structure.
- If the disc slips into the spinal cord area it can result in sensory loss and weakness below the effected level along with balance and possible bowel and bladder issues.
Treating a Slipped Disc
Treatment of a slipped disc or injury will depend on the severity of the condition. When treating acute disc or back problems treatment recommendations include:
- Rest. Avoid activities like bending, twisting, prolonged sitting, and lifting.
- Anti-inflammatory drugs and pain medications.
- Apply ice to the thoracic spine to help reduce pain and associated muscle spasm. Apply ice 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 discs, muscles and lumbar spine.
In mild cases many patients 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.
In addition to performing a thorough examination your physician may order the following tests to make a more precise diagnosis:
- X-ray to determine if there is any joint degeneration, fractures, bony malformations, arthritis, tumors or infections 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.
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.
- If over the counter medications are not effective your physician may recommend stronger prescription 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.
- Prescription medication designed specifically to reduce nerve damage and 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 bulging discs can be treated successfully without surgery. In the case of conditions that do not respond to conservative care, surgery may be recommended. If you continue to experience some of the following symptoms, your doctor may recommend you for a surgical procedure:
- Increase in radiating or radicular pain
- Pain or nerve damage that gets worse
- The development of increased weakness
- An increase in numbness or paraesthesia
- 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