Thoracic disc prolapse

Saul S Schwarz MD (Dr. Schwarz of the University of Colorado Health Sciences has no relevant financial relationships to disclose.)
Randolph W Evans MD, editor. (Dr. Evans of Baylor College of Medicine received honorariums from Allergan, Avanir, DepoMed, and Pernix for speaking engagements and honorariums from Alder, Lilly, and Promius for advisory board membership.)
Originally released November 22, 1999; last updated January 22, 2017; expires January 22, 2020

This article includes discussion of thoracic disc prolapse, thoracic disc disease, thoracic disc herniation, and thoracic intervertebral disc disease. The foregoing terms may include synonyms, similar disorders, variations in usage, and abbreviations.

Overview

Thoracic intervertebral disc disease is a rare source of pain and neurologic dysfunction, and it is not as well known to most clinicians as lumbar or cervical disc disease. Thoracic disc disease has been described as causing many different symptoms without a discrete clinical syndrome. Although back pain is usually the most common presenting symptom, many other presentations have been described that are often misleading. The author of this article provides an updated overview of the disease, including presentation, presumed mechanisms of injury, and updated diagnosis and management principles, both surgical and nonsurgical.

Key points

 

• Thoracic disc disease is an often-missed diagnosis in patients with neurologic deficits.

 

MRI is the key imaging modality for diagnosis of disc prolapse and cord compression. For patients who have contraindications for MRI scans, CT myelogram is an acceptable alternative. Noncontrast CT may be critical in demonstrating the degree and location of calcification in the disc rupture.

 

• Surgical management of the offending disc fragment or decompression of the spinal cord can lead to recovery of neurologic function.

 

• New, minimally invasive techniques of thoracic discectomy have been developed.

Historical note and terminology

Thoracic intervertebral disc disease is a rare source of pain and neurologic dysfunction compared to cervical and lumbar pathologies (Hawk 1936; Haley and Perry 1950; Love and Kiefer 1950). Spinal cord injury from ruptured thoracic disc was first reported in 1838 (Key 1838). In 1911 Middleton and Teacher reported a patient who “felt something crack in his back” while lifting a heavy plate, which forced him to bed. He progressed to flaccid paraplegia later that day and died 16 days later of urinary tract infection. An autopsy of the patient showed a T11 to T12 herniated disc with spinal cord compression (Middleton and Teacher 1911). Microscopic examination revealed hemorrhage, necrosis, and thrombosed vessels in the spinal cord. Since then, there have been numerous reports of clinically significant herniated thoracic discs as causes of pain and neurologic abnormality in patients.

Although the potential for a devastating acute paraplegic manifestation of thoracic disc herniation exists, it is often difficult to decide if an operative intervention is necessary, even when thoracic disc disease is discovered. The rib cage provides an "internal brace" that impedes onset or progression of thoracic disc herniation, whereas no such protection is available to the cervical or lumbar spine.

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