Thoracic Discogenic Pain Syndrome Treatment & Management

  • Author: Gerard A Malanga, MD; Chief Editor: Sherwin SW Ho, MD   more...
 
Updated: Dec 14, 2011
 

Acute Phase

Rehabilitation Program

Physical Therapy

During the acute phase of a rehabilitation program for thoracic disc herniations, the focus of treatment is reducing pain symptoms. Instruction in posture and body mechanics in activities of daily living is aimed at protecting injured structures, reducing symptoms, and preventing further injury. Educate patients to avoid positions that increase intradiscal pressure, such as sitting, bending, and lifting.

A short course of bed rest of 2 days or shorter may provide some beneficial effects secondary to pain modulation and reduction of intradiscal pressure. However, longer courses of bed rest may have detrimental effects on bones, connective tissue, muscle, and cardiovascular fitness. Emphasis on activity modification, rather than strict bed rest, is recommended to avoid the unwanted effects of immobilization.

Modalities such as electrical stimulation should be limited to the initial stages of treatment so that patients can progress quickly to more active treatment that addresses restoration of motion and strengthening.

Surgical Intervention

Surgery for removal of a herniated thoracic disc is often a technically difficult procedure. The limited space available for spinal cord manipulation and the relatively tenuous blood supply increase the susceptibility of the spinal cord to injury during decompression. However, in the hands of a competent surgeon, carefully selected patients have had good outcomes.[10, 11, 12, 13]

No strict evidence-based indications have been developed for surgical thoracic discectomy; however, general guidelines have been determined. The general agreement is that surgery is indicated when myelopathic signs are present. These patients may benefit from early surgery because the rate of recovery diminishes when more advanced neurologic deficits are present. Surgical indications in cases of radiculopathy are less clear, because many patients' conditions respond to conservative management. However, surgery is a viable option for patients with radicular symptoms who have not had a satisfactory response to conservative care. Patients with purely discogenic or axial pain are not generally treated surgically.[14]

Many approaches can be used to remove herniated thoracic discs. The earliest surgical approach, used in the early 1900s, was a posterior laminectomy. That technique was used for many years until numerous studies demonstrated it produces poor results and has an unacceptable complication rate. In current practice, many other surgical options are available for thoracic disc herniations, all of which are modifications of 3 basic approaches.

The 3 approaches are the anterolateral, the lateral, and the posterolateral. The anterolateral approaches include transthoracic, trans-sternal, and thoracoscopic.[15] The lateral approaches include costotransversectomy, lateral extracavitary, and parascapular. The posterolateral approaches are a transpedicular or transfacet pedicle-sparing procedure.

The decision regarding the most appropriate surgical approach is individualized and based on the consistency of the compressive disc, the level of herniation, its relationship to the spinal cord, and the likelihood of dural involvement. The surgeon’s familiarity with the particular approach must also be taken into consideration.

Consultations

The presence of significant myelopathic signs or progressive neurologic deficit is an absolute indication for immediate consultation with and intervention by a neurosurgeon.

Other Treatment

Thoracic epidural steroid injections should be reserved for patients with an unacceptable level of pain that has not responded to other conservative treatments. No rationale exists for performing a series of injections.

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Recovery Phase

Rehabilitation Program

Physical Therapy

Physical therapy should emphasize extension-based strengthening exercises, postural training, and education in proper posture and body mechanics. Pain during this phase should be judiciously managed with nonsteroidal anti-inflammatory drugs (NSAIDs), acetaminophen, or other oral agents to allow the patient to adequately participate in therapy.

With the progression of therapy and control of painful symptoms, a spine stabilization program should follow. With spine stabilization exercises, the goal is to teach the patient how to find and maintain a neutral spine during everyday activities. The neutral spine position is specific to the individual and is determined by the pelvic and spine posture that places the least stress on the elements of the spine and supporting structures. In classic discogenic pain, the neutral spine has an extension bias.

In classic posterior element pain and spinal stenosis, both of which may result from the ongoing degenerative cascade initiated by disc degeneration, the neutral spine may have a mild flexion bias. Dynamic spinal stabilization may be used with the McKenzie approach to provide dynamic muscular control and to protect the spine from biomechanical stresses, including tension, compression, torsion, and shear. Spinal stabilization emphasizes the synergistic activation of the trunk and spinal musculature in the midrange position.

Strengthening of the abdominal and gluteal muscle groups is emphasized, because these muscles attach to the thoracolumbar fascial support system, one of the potential spine stabilizing structures. The overall goals of this comprehensive exercise program are to reduce pain, to develop the muscular support of the trunk and spine, and, ultimately, to diminish the overall stress to the intervertebral disc and other static stabilizers of the spine.

Surgical Intervention

See Surgical Intervention under Acute Phase.

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Maintenance Phase

Rehabilitation Program

Physical Therapy

The maintenance phase represents the final phase of the rehabilitation process following thoracic disc herniation or thoracic discogenic pain syndrome. Eccentric muscle strengthening exercises, including more dynamic conditioning exercises, are added to the program. In addition, sport-specific training should be incorporated so that the athlete can maintain a neutral spine in all recreational activities.

The goals of a comprehensive spine rehabilitation program are met when the individual no longer demonstrates the original symptoms and when (1) full range of motion of the spine, (2) normal strength and flexibility, and (3) normal sport-specific mechanics are demonstrated.

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Contributor Information and Disclosures
Author

Gerard A Malanga, MD  Director of Pain Management, Overlook Hospital; Director of PM&R Sports Medicine Fellowship, Atlantic Health; Clinical Professor, Department of Physical Medicine and Rehabilitation, UMDNJ-New Jersey Medical School; Clinical Chief, Rehabilitation Medicine and Electrodiagnosis, St Michael's Medical Center; Fellow, American College of Sports Medicine

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, American Institute of Ultrasound in Medicine, International Spine Intervention Society, and North American Spine Society

Disclosure: Cephalon Honoraria Speaking and teaching; Endo Honoraria Speaking and teaching; Genzyme Honoraria Speaking and teaching; Prostakan Honoraria Speaking and teaching; Pfizer Consulting fee Speaking and teaching

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.

Specialty Editor Board

Craig C Young, MD  Professor, Departments of Orthopedic Surgery and Community and Family Medicine, Medical Director of Sports Medicine, Director of Primary Care Sports Medicine Fellowship, 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, and Phi Beta Kappa

Disclosure: Nothing to disclose.

Francisco Talavera, PharmD, PhD  Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Medscape Salary Employment

Russell D White, MD  Professor of Medicine, Professor of Orthopedic Surgery, Director of Sports Medicine Fellowship Program, Medical Director, Sports Medicine Center, Head Team Physician, University of Missouri-Kansas City Intercollegiate Athletic Program, Department of Community and Family Medicine, University of Missouri-Kansas City School of Medicine, Truman Medical Center-Lakewood

Russell D White, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Family Physicians, American Association of Clinical Endocrinologists, American College of Sports Medicine, American Diabetes Association, and American Medical Society for Sports Medicine

Disclosure: Nothing to disclose.

Jon B Whitehurst, MD  Clinical Instructor of Surgery, University of Illinois College of Medicine; Partner, 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 Division of the Biological Sciences, The Pritzker School of Medicine

Sherwin SW Ho, MD is a member of the following medical societies: American Academy of Orthopaedic Surgeons, American Orthopaedic Society for Sports Medicine, Arthroscopy Association of North America, and Herodicus Society

Disclosure: Breg, Inc. Consulting fee Consulting; Biomet, Inc. Consulting fee Consulting; GMV, Inc. Arthroscopy Simulator Evaluation and teaching; Smith and Nephew Grant/research funds Fellowship funding; DJ Ortho Grant/research funds Course funding; Athletico Physical Therapy Grant/research funds Course, research funding

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Axial magnetic resonance image of a thoracic herniated disc.
Sagittal magnetic resonance image of a lower thoracic herniated disc.
 
 
 
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