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Thoracic Discogenic Pain Syndrome: Differential Diagnoses & Workup

Author: Gerard A Malanga, MD, Founder and Director, New Jersey Sports Medicine Institute; Director of Pain Management, Overlook Hospital; Director of Sports Medicine, Sports Medicine Fellowship Director, Mountainside Hospital; Clinical Chief, Rehabilitation Medicine and Electrodiagnosis, St Michael's Medical Center; Medical Director, Consultant, Horizon Healthcare Worker's Compensation Services, Blue Cross and Blue Shield Worker's Compensation
Coauthor(s): James P McLean, MD, Staff Physician, Department of Physical Medicine and Rehabilitation, Kessler Institute for Rehabilitation, University of Medicine and Dentistry of New Jersey; Irfan Alladin, MD, Staff Physician, Department of Physical Medicine and Rehabilitation, University of Medicine and Dentistry at New Jersey; Qing Tai, MD, PhD, Staff Physician, Department of Physical Medicine and Rehabilitation, University of Medicine and Dentistry of New Jersey; Stephen G Andrus, MD, Sports Medicine Fellow, Department of Physical Medicine and Rehabilitation, Kessler Institute for Rehabilitation, University of Medicine and Dentistry of New Jersey; Rachael Smith, DO, Consulting Staff, Mid-Atlantic Pain Institute, PC
Contributor Information and Disclosures

Updated: Jan 8, 2009

Differential Diagnoses

Cervical Disc Injuries
Lumbosacral Spondylolisthesis
Cervical Radiculopathy
Lumbosacral Spondylolysis
Lumbosacral Disc Injuries
Lumbosacral Discogenic Pain Syndrome
Lumbosacral Radiculopathy

Other Problems to Be Considered

Amyotrophic lateral sclerosis
Aneurysms
Cerebral ischemia and infarct and arteriovenous malformations
Cholecystitis
Herpes zoster
Intercostal neuralgia
Intramedullary and extramedullary spinal cord tumors, demyelinating disease
Multiple sclerosis
Parasagittal brain tumors
Peripheral neuropathy
Plexopathy
Psychiatric disorders
Retroperitoneal neoplasms
Root avulsion
Transverse myelitis

Workup

Imaging Studies

Plain radiography
 
 The primary role of radiographs in the evaluation of back pain is to evaluate for fracture, tumors, or infection. However, radiographs can also provide some useful information when evaluating for thoracic disc herniations. Osteophyte formation, disc-space narrowing, and kyphosis are signs of disc degeneration and often occur in conjunction with disc herniation. However, these findings have a low specificity for the diagnosis of thoracic disc herniation. Although not diagnostic, disc calcification is a more reliable finding when evaluating for thoracic disc herniation on radiographs. This finding is present in up to 70% of patients with thoracic disc herniation and is seen in only 4-6% of patients without thoracic disc herniation.
 
CT myelography
 
 With the advent of MRI, CT myelography is used less frequently in the evaluation of thoracic discogenic pain syndrome. MRI has diagnostic advantages over CT myelography and does not involve injection of contrast into the epidural space. However, CT myelography is good for diagnosing lateral herniations and calcification, and this imaging modality is often used in preoperative planning.  
 
MRI
 
 MRI is the most commonly used diagnostic test in the evaluation of thoracic disc herniation. It is the screening test of choice and is extremely sensitive for detecting disc abnormalities. Advantages of MRI compared with CT scanning or CT scanning with myelography include better visualization of the soft-tissue structures, earlier recognition of disc degeneration, and the ability to evaluate in the sagittal plane. 

Sagittal magnetic resonance image of a lower thor...

Sagittal magnetic resonance image of a lower thoracic herniated disc.

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Sagittal magnetic resonance image of a lower thor...

Sagittal magnetic resonance image of a lower thoracic herniated disc.


 
MRI can be used to determine the size and location of the disc herniation and to characterize it as a protrusion, extrusion, or sequestration. Although helpful in preoperative planning, these features may not be helpful in determining a prognosis. Brown et al retrospectively reviewed the MRI results of 55 patients with symptomatic thoracic disc herniations.7  Fifteen patients ultimately needed surgery and 40 patients did well with conservative management. MRI could not help distinguish the discs in the surgically treated group from the discs in the conservatively treated group.7  

A more useful way of determining the severity of thoracic disc herniation with MRI may be quantifying the amount of neural compression. One such grading system suggested by Kaplan is as follows8 : 

  • Mild: The anterior epidural fat is not obliterated.
  • Moderate: The epidural fat is obliterated, and the thecal sac is displaced.
  • Severe: The cord is effaced or the nerve root(s) is displaced.

Despite the usefulness of MRI, it does have limitations. As technology has improved, thoracic disc herniations are more easily recognized. However, all of these thoracic disc herniations may not be clinically significant. Wood et al evaluated 90 individuals without thoracic pain to determine the frequency of abnormalities.9 Intervertebral degenerative changes, annular abnormalities, or both were found in 73% of the subjects; herniation was seen in 37% of the subjects. 

MRI is also less sensitive for the evaluation of annular tears, particularly in the thoracic region. The high-intensity zone that commonly represents radial tears in cervical and lumbar MRIs is not seen as often in the thoracic region. These limitations underscore the importance of the patient's history and physical examination. MRI plays an important role in the evaluation of thoracic discogenic pain syndrome, but the results must be interpreted in light of the clinical findings and with knowledge of the limitations of MRI.

Other Tests

Electrodiagnosis
 
 Electrodiagnostic studies, including nerve conduction study (NCS), needle electromyography (EMG), and somatosensory evoked potentials (SSEPs), can be useful adjuncts to the history and physical examination. NCS and EMG can be used in the evaluation of thoracic radiculopathy; however, their utility is limited by the limited number of tests, the lack of their ability to localize the level of involvement, and the risk of pneumothorax or penetration of the abdominal cavity with some techniques. However, NCS and EMG can be extremely useful in excluding other possible diagnoses, such as cervical radiculopathy, lumbosacral radiculopathy, and peripheral neuropathy.

SSEPs should be considered in cases in which it is unclear whether clinical symptoms are due to an upper motor neuron or lower motor neuron process. SSEPs can help make this distinction and can assist in directing subsequent treatment accordingly.  
 
Discography
 
 Thoracic discography may be considered in patients who are considering surgical intervention for predominantly axial back pain that is thought to be discogenic in nature. Discograms are most useful when they demonstrate single-level concordant pain that is associated with endplate irregularities or annular tears and normal discs at adjacent levels. However, the results of thoracic discography should be interpreted with caution.  
 
Wood et al showed that 55% of discograms performed in patients with symptomatic thoracic pain revealed concordant pain. Whether this large number of positive results represents multilevel disease or a high false-positive rate in the population is unclear. Furthermore, 2 of 10 asymptomatic patients demonstrated pain that could be interpreted as a positive result. Wood et al concluded that long-term prospective studies of surgical outcomes and their correlation with discography results are warranted.

Procedures

Epidural corticosteroid injections
 
For patients with a thoracic radiculopathy as a result of a thoracic disc herniation whose condition has not responded to conservative therapy, thoracic epidural steroid injections are a reasonable treatment option. The efficacy of epidural corticosteroid injections has been documented in cervical and lumbar radiculopathies. However, because of the small number of documented cases of thoracic discogenic pain syndrome, no study has been performed to evaluate efficacy for this specific condition.

More on Thoracic Discogenic Pain Syndrome

Overview: Thoracic Discogenic Pain Syndrome
Differential Diagnoses & Workup: Thoracic Discogenic Pain Syndrome
Treatment & Medication: Thoracic Discogenic Pain Syndrome
Follow-up: Thoracic Discogenic Pain Syndrome
Multimedia: Thoracic Discogenic Pain Syndrome
References
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Further Reading

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Keywords

thoracic discogenic pain syndrome, thoracic disc herniation, thoracic disk herniation, thoracic degenerative disc disease, thoracic degenerative disk disease, TDH, back pain, mid back pain, midback pain, TDPS, TDP syndrome, thoracic pain, thoracic disc injuries

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Contributor Information and Disclosures

Author

Gerard A Malanga, MD, Founder and Director, New Jersey Sports Medicine Institute; Director of Pain Management, Overlook Hospital; Director of Sports Medicine, Sports Medicine Fellowship Director, Mountainside Hospital; Clinical Chief, Rehabilitation Medicine and Electrodiagnosis, St Michael's Medical Center; Medical Director, Consultant, Horizon Healthcare Worker's Compensation Services, Blue Cross and Blue Shield Worker's Compensation
Gerard A Malanga, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Physical Medicine and Rehabilitation, American College of Sports Medicine, North American Spine Society, and Physiatric Association of Spine, Sports and Occupational Rehabilitation
Disclosure: Nothing to disclose.

Coauthor(s)

James P McLean, MD, Staff Physician, Department of Physical Medicine and Rehabilitation, Kessler Institute for Rehabilitation, University of Medicine and Dentistry of New Jersey
Disclosure: Nothing to disclose.

Irfan Alladin, MD, Staff Physician, Department of Physical Medicine and Rehabilitation, University of Medicine and Dentistry at New Jersey
Irfan Alladin, MD is a member of the following medical societies: American Academy of Physical Medicine and Rehabilitation
Disclosure: Nothing to disclose.

Qing Tai, MD, PhD, Staff Physician, Department of Physical Medicine and Rehabilitation, University of Medicine and Dentistry of New Jersey
Qing Tai, MD, PhD is a member of the following medical societies: American Academy of Physical Medicine and Rehabilitation, American Paraplegia Society, and Society for Neuroscience
Disclosure: Nothing to disclose.

Stephen G Andrus, MD, Sports Medicine Fellow, Department of Physical Medicine and Rehabilitation, Kessler Institute for Rehabilitation, University of Medicine and Dentistry of New Jersey
Stephen G Andrus, MD is a member of the following medical societies: American Academy of Physical Medicine and Rehabilitation, American College of Sports Medicine, American Medical Association, and Physiatric Association of Spine, Sports and Occupational Rehabilitation
Disclosure: Nothing to disclose.

Rachael Smith, DO, Consulting Staff, Mid-Atlantic Pain Institute, PC
Rachael Smith, DO is a member of the following medical societies: American Academy of Physical Medicine and Rehabilitation, American Osteopathic Association, Association of Academic Physiatrists, and Physiatric Association of Spine, Sports and Occupational Rehabilitation
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

Russell D White, MD, Professor of Medicine, Department of Community and Family Medicine, University of Missouri-Kansas City School of Medicine, Truman Medical Center Lakewood
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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