eMedicine Specialties > Sports Medicine > Spine

Thoracic Disc Injuries

Author: Kambiz Hannani, MD, Consulting Staff, Department of Orthopedic Surgery, Citrus Valley Medical Center
Contributor Information and Disclosures

Updated: Dec 21, 2007

Introduction

Background

Thoracic disc injury, first described in 1838, is an uncommon site of injury owing to the stabilizing effect of the rib cage.1 The similarity of symptoms to lumbar disc herniation makes the diagnosis of a thoracic disc injury difficult,2,3,4,5,6 but the process tends to be self-limiting and rarely requires surgical intervention.4

(See also the eMedicine articles Disk Herniation and Thoracic Spine, Trauma [in the Radiology section], Thoracic Discogenic Pain Syndrome [in the Sports Medicine section], Lumbar Disc Disease [in the Neurosurgery section], and Herniated Nucleus Pulposus [in the Orthopedic Surgery section], as well as Return to Contact Sports After Spinal Surgery and Thoracoscopic Spine Surgery for Decompression and Stabilization of the Anterolateral Thoracic and Lumbar Spine on Medscape.)

For excellent patient education resources, visit eMedicine's Bone Health Center, Back, Ribs, Neck, and Head Center, Back, Neck, and Head Injury Center, and Muscle Disorders Center. Also, see eMedicine's patient education articles Back Pain and Chronic Pain.

Frequency

United States

The incidence of thoracic disc injuries is 1 in 1 million persons per year, and these injuries account for 0.25-0.75% of all disc herniations.7

Functional Anatomy

The thoracic discs are unusually stable compared with the cervical and lumbar discs. The stability of the thoracic discs is secondary to the surrounding rib cage, with the stabilizing effect of the rib articulations. However, the blood supply of the thoracic spine is more tenuous than the cervical and lumbar spine, especially at the T4-T9 watershed area, which is more prone to ischemic injury.

Sport-Specific Biomechanics

The facet orientation in the thoracic spine is vertical, with a slight medial angulation. This orientation allows for easier lateral bending and rotation versus pure bending. Biomechanical studies have shown that intervertebral discs are at the highest risk of injury when combined with bending and torsional forces. Therefore, the thoracic spine discs are at a decreased risk of injury because of the decreased bending potential in this segment of the spine.

The spinal cord-to-canal ratio (the ratio of the cross-sectional area of the cord to the cross-sectional area of the spinal canal) is 40% in the thoracic spine versus 25% in the cervical spine. The thoracic spine is also naturally kyphotic. These 2 facts make the thoracic spine more sensitive to cord compression from disc herniation.

Clinical

History

Determine the location and type of the patient's pain. Is the pain mainly located in the thoracolumbar spine, and is it radicular or mechanical in nature?

  • Thoracic disc disease may emulate the symptoms of lumbar disc disease.
    • Shooting pain down the legs implies nerve root irritation versus cord compression.
    • Pain in the thoracic area signifies mechanical pain that is possibly secondary to fractures, degenerative disc disease, tumors, or infections. (See also the eMedicine articles Degenerative Disk Disease and Thoracic Spine Fractures and Dislocations [in the Orthopedic Surgery section].)
    • Night pain that wakes the patient is suggestive of infection or an oncologic process.
  • Cord compression is present with myelopathy, which requires immediate attention.2 (See also the eMedicine articles Spinal Stenosis [in the Orthopedic Surgery section] and Spinal Cord, Topographical and Functional Anatomy [in the Neurology section].) Myelopathy is seen with the following:
    • The presence of clonus or a positive Babinski reflex
    • Bowel and bladder dysfunction (seen in up to 20% of symptomatic discs)
  • High thoracic (T2-T5) herniation mimics cervical disc disease. (See also the eMedicine article Cervical Disc Disease.)
    • Patients can present with upper extremity involvement, including Horner syndrome. (See also the eMedicine articles Horner Syndrome [in the Ophthalmology section] and Horner Syndrome [in the Oncology section].)
    • If myelopathy is present, a negative result from the Hoffmann test makes cervical spine involvement unlikely. A positive result from the Hoffmann test is seen when the middle-finger metacarpophalangeal joint and the proximal interphalangeal joints are kept extended; a flexion reflex of the thumb is seen when the distal interphalangeal joint is flicked or suddenly extended. This is known as the Hoffmann sign.
  • Radicular symptoms include pain/paresthesias or dysesthesias in a dermatomal distribution. Dermatome T10 is usually involved.

Physical

The physical examination for thoracic disc injuries includes the following: palpation over the thoracic spine; range-of-motion (ROM) examination of the hips, knees, and ankles; straight leg-raise test; motor and sensory examination; and reflex examination.

  • Palpation
    • Palpate the entire region of the thoracic spine.
    • Muscle spasms can be identified by palpation.
  • ROM examination
    • Assess the patient's ROM throughout the hips, knees, and ankles.
    • A ROM examination, especially of the hip, can confirm the presence of radiculopathy versus referred pain from hip/knee pathology (eg, arthritis). (See also the Arthritis Resource Center on Medscape.)
    • ROM in the thoracic spine can be affected by the type of pathology. Arthritic changes that cause mechanical pain usually limit extension; radiculopathy that is seen with disc herniation generally causes increasing pain with flexion.
    • Bilateral straight leg-raise tests should be completed, and the patient's available ROM and symptoms should be noted and documented.
  • Motor examination of all the lumbar roots, including L2-L4 (knee extension), L4 (inversion), L5 (dorsiflexion), and S1 (eversion and plantar flexion) is helpful for evaluating nerve root involvement in the lumbar spine and cord compression in the thoracic spine.
  • Sensory examination
    • Sensory examination of the dermatomes, especially in the thoracoabdominal region, can help the clinician identify the level of involvement.
    • The nipple is innervated by T4; the xiphoid, T7; the umbilicus, T10; and the inguinal region, T12.
  • Reflex testing
    • The knee (L4) and ankle (S1) reflexes should be tested.
    • The abdominal reflexes and cremasteric reflex (check for symmetry and presence) can help the clinician identify myelopathy and cord compression.
  • Vascular examination of the dorsalis pedis artery, posterior tibial artery, and femoral artery can rule out other causes of the patient's symptoms.

Causes

The progressive wear and tear that is noted with degenerative disc disease increases the risk of injury via trauma. Contributing factors to disc injury include the following:

  • Age
  • Trauma
  • Smoking
  • Obesity
  • Sedentary lifestyle
  • Poor physical fitness

More on Thoracic Disc Injuries

Overview: Thoracic Disc Injuries
Differential Diagnoses & Workup: Thoracic Disc Injuries
Treatment & Medication: Thoracic Disc Injuries
Follow-up: Thoracic Disc Injuries
References
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References

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Further Reading

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Keywords

thoracic disc/disk herniation, thoracic degenerative disc/disk disease, thoracic DDD, thoracic herniated nucleus pulposus, thoracic HNP, thoracic disk injuries

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Contributor Information and Disclosures

Author

Kambiz Hannani, MD, Consulting Staff, Department of Orthopedic Surgery, Citrus Valley Medical Center
Kambiz Hannani, MD is a member of the following medical societies: Phi Beta Kappa
Disclosure: Nothing to disclose.

Medical Editor

Craig C Young, MD, Professor, Departments of Orthopedic Surgery and Community and Family Medicine, Medical Director of Sports Medicine, Sports Medicine Fellowship Director, Medical College of Wisconsin
Craig C Young, MD is a member of the following medical societies: American Academy of Family Physicians, American College of Sports Medicine, American Medical Society for Sports Medicine, Phi Beta Kappa, and Wilderness Medical Society
Disclosure: Nothing to disclose.

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: Nothing to disclose.

Managing Editor

Henry T Goitz, MD, Chief, Sports Medicine, Associate Professor, Department of Orthopaedic Surgery, Medical College of Ohio
Henry T Goitz, MD is a member of the following medical societies: American Academy of Orthopaedic Surgeons and American Orthopaedic Society for Sports Medicine
Disclosure: Nothing to disclose.

CME Editor

Jon B Whitehurst, MD, Clinical Instructor of Surgery, University of Illinois College of Medicine; Partner and Executive Board Member, Rockford Orthopedic Associates; Orthopedic Chairman, Rockford Memorial Hospital
Jon B Whitehurst, MD is a member of the following medical societies: American Academy of Orthopaedic Surgeons, American Orthopaedic Society for Sports Medicine, and Arthroscopy Association of North America
Disclosure: Nothing to disclose.

Chief Editor

Sherwin SW Ho, MD, Associate Professor, Department of Surgery, Section of Orthopedic Surgery and Rehabilitation Medicine, University of Chicago
Sherwin SW Ho, MD is a member of the following medical societies: American Academy of Orthopaedic Surgeons, American Orthopaedic Society for Sports Medicine, and Arthroscopy Association of North America
Disclosure: Nothing to disclose.

 
 
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