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Thoracic Discogenic Pain Syndrome: Treatment & Medication
Updated: Jan 8, 2009
- Overview
- Differential Diagnoses & Workup
- Treatment & Medication
- Follow-up
- Multimedia
Treatment
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.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.10
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. 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.
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.
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.
Medication
Various medications can be used in the treatment of thoracic disc herniations, including acetaminophen, NSAIDs, muscle relaxants, opioid analgesics, oral corticosteroids, and antidepressants. Before prescribing these medications, the physician should be aware of the contraindications, common adverse effects, and mode of action of each agent.
Nonsteroidal Anti-inflammatory Drugs (NSAIDs)
Acetaminophen is used for its anti-inflammatory effects. The dose needed to produce anti-inflammatory effects substantially differs from that for analgesic effects. Most NSAIDs achieve only analgesic effects because the dosage prescribed is too small and too infrequent to produce an anti-inflammatory effect.
The risks associated with NSAIDs are particularly pertinent in elderly persons and patients with a history of peptic ulcer diseases, hypertension, or renal insufficiency. Newer-generation NSAIDs selectively interact with the cyclooxygenase-2 (COX-2) receptors and have a lower gastrointestinal risk. Prolonged use of these medications generally is not recommended for most low back problems.
Related eMedicine topics:
Abdominal Pain in Elderly Persons
Toxicity, Nonsteroidal Anti-inflammatory Agents
Ibuprofen (Motrin, Ibuprin)
DOC for patients with mild to moderate pain. Inhibits inflammatory reactions and pain by decreasing prostaglandin synthesis.
Adult
400-600 mg PO q6h with food
Pediatric
Not established
Coadministration with aspirin increases the risk of serious NSAID-related adverse effects; probenecid may increase the concentrations and, possibly, the toxicity of NSAIDs; may decrease the effect of hydralazine, captopril, and beta-blockers; may decrease the diuretic effects of furosemide and thiazides; may increase PT duration when taking anticoagulants (instruct patients to watch for signs of bleeding); may increase the risk of methotrexate toxicity; phenytoin levels may be increased when administered concurrently
Documented hypersensitivity; aspirin/NSAID-induced asthma; bleeding disorders; concurrent warfarin therapy; history of GI bleeding
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
D - Fetal risk shown in humans; use only if benefits outweigh risk to fetus
Precautions
Caution in patients with a history of nasal polyps, CHF, hypertension, and GI upset
Celecoxib (Celebrex)
Inhibits primarily COX-2. COX-2 is considered an inducible isoenzyme, one induced with pain and inflammatory stimuli. Inhibition of COX-1 may contribute to NSAID GI toxicity. At therapeutic concentrations, COX-1 isoenzyme is not inhibited; thus, GI toxicity may be decreased. Seek the lowest dose for each patient.
Adult
200 mg/d PO qd; alternatively, 100 mg PO bid
Pediatric
Not established
Coadministration with fluconazole may cause an increase in celecoxib plasma concentrations because of inhibition of celecoxib metabolism; coadministration with rifampin may decrease celecoxib plasma concentrations.
Documented hypersensitivity
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
Precautions
May cause fluid retention and peripheral edema; caution in patients with compromised cardiac function, hypertension, and conditions predisposing to fluid retention; caution in the presence of severe heart failure and hyponatremia because circulatory hemodynamics may deteriorate; NSAIDs may mask the usual signs of infection (caution in the presence of existing controlled infections); evaluate symptoms and signs that suggest liver dysfunction or in the presence of abnormal liver laboratory test results
Analgesics
Use of opioids should be limited to pain that is unresponsive to alternative medication. Opioids can be prescribed for acute disc herniation to facilitate participation in an active rehabilitation program. These agents should be used on a defined dosing schedule and not on an as-needed basis. An adequate baseline dose should be established to achieve analgesia. Use of nonopioid analgesics, such as tramadol, is also an option.
Related eMedicine topics:
Opioid Abuse
Toxicity, Narcotics
Oxycodone (OxyContin)
Analgesic with multiple actions similar to those of morphine; may produce less constipation, smooth muscle spasm, and depression of cough reflex than similar analgesic doses of morphine.
Adult
10 mg PO bid initially
Pediatric
Not established; adjust for weight
Phenothiazines may antagonize analgesic effects; MAOIs, general anesthesia, CNS depressants, and TCAs may increase toxicity.
Patients with a significant history of respiratory depression whose respiratory functions are not being monitored closely; severe bronchial asthma; patients with hypocarbia; paralytic ileus
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
D - Fetal risk shown in humans; use only if benefits outweigh risk to fetus
Precautions
Caution in the presence of COPD, emphysema, and renal insufficiency
Tramadol (Ultram)
Inhibits ascending pain pathways, altering perception of and response to pain. Also inhibits reuptake of norepinephrine and serotonin.
Adult
50-100 mg PO q4-6h; not to exceed 400 mg/d
Pediatric
Not established
Significantly decreases carbamazepine effects; cimetidine increases toxicity; risk of serotonin syndrome with the coadministration of antidepressants
Documented hypersensitivity; opioid-dependent patients; concurrent use of MAOIs or within 14 d; use of SSRIs, TCAs, or opioids; acute alcohol intoxication
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
Can cause dizziness, nausea, constipation, sweating, and pruritus; caution in additive sedation with alcohol or TCAs, pregnancy, breastfeeding, or seizures; abrupt discontinuation can precipitate opioid withdrawal symptoms; adjust the dose in the presence of liver disease, myxedema, hypothyroidism, and hypoadrenalism; tolerance or dependency may develop with extended use
Muscle Relaxants
Medications categorized as muscle relaxants may be helpful in some patients with low back pain; these agents seem to have additional beneficial effects when used in conjunction with NSAIDs. Muscle relaxants can be used as short-term adjunctive medications, and they should be taken at bedtime to take advantage of their sedating effects.
Cyclobenzaprine (Flexeril)
Skeletal muscle relaxant that acts centrally and reduces the motor activity of tonic somatic origins that influence both alpha and gamma motor neurons. Structurally related to TCAs and, thus, has some of the same liabilities.
Adult
10 mg PO tid initially; not to exceed 60 mg/d
Pediatric
Not established
Coadministration with MAOIs and TCAs may increase toxicity; may have an additive effect when used concurrently with anticholinergics; effects of alcohol, CNS depressants, and barbiturates may be enhanced
Acute recovery phase of MI; history of arrhythmia; heart block; conduction disturbances; hyperthyroidism
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
Precautions
Caution in patients with angle-closure glaucoma and urinary hesitance
Metaxalone (Skelaxin)
Prescribed for use as a muscle relaxant. The mechanism of action not firmly established, but it may act as a CNS depressant and direct pain reliever. No direct action on contractile mechanism of striated muscle. Can be used as an adjunct pain reliever for the short term in situations of severe myofascial strain.
Adult
800 mg (2 tab) PO tid/qid
Pediatric
<12 years: Not recommended
>12 years: Administer as in adults.
None reported
Documented hypersensitivity; known tendency to drug-induced hemolytic anemia or other anemias; significantly impaired renal or hepatic function
Pregnancy
D - Fetal risk shown in humans; use only if benefits outweigh risk to fetus
Precautions
Caution in patients with hepatic impairment
Corticosteroids
Corticosteroids are potent anti-inflammatory medications, and they represent a theoretically useful agent in the treatment of patients with radiculopathy due to local inflammation that results from disc injury or herniation.
Related eMedicine topics:
Corticosteroid-Induced Myopathy
Corticosteroid Injections of Joints and Soft Tissues
Prednisone (Deltasone, Orasone, Meticorten)
Decreases inflammation by suppressing migration of polymorphonuclear leukocytes and reversing increased capillary permeability.
Adult
60-80 mg/d PO qd or divided bid initially; taper over 8-10 d
Pediatric
Not established
Coadministration with digoxin may increase digitalis toxicity secondary to hypokalemia; estrogens may increase levels; phenobarbital, phenytoin, and rifampin may decrease levels (adjust dose); monitor for hypokalemia in patients concurrently taking diuretics
Documented hypersensitivity; viral, fungal, or tubercular skin infections
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
Hyperglycemia, edema, osteonecrosis, peptic ulcer disease, hypokalemia, osteoporosis, euphoria, psychosis, growth suppression, myopathy, and infections are possible complications of glucocorticoid use.
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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References
Epstein NE, Epstein JA, Rosenthal AD. Thoracic disc disease. In: Dee R, ed. Principles of Orthopedic Practice. Vol 2. New York , NY: McGraw-Hill, Inc; 1989:991-7.
Mirkovic S, Cybulski GR. Thoracic disc herniations. In: Garfin SR, Vaccaro AR, eds. Orthopaedic Knowledge Update V. Rosemont, Ill: American Academy of Orthopaedic Surgeons; 1996.
Awwad EE, Martin DS, Smith KR Jr, Baker BK. Asymptomatic versus symptomatic herniated thoracic discs: their frequency and characteristics as detected by computed tomography after myelography. Neurosurgery. Feb 1991;28(2):180-6. [Medline].
Wood KB, Garvey TA, Gundry C, Heithoff KB. Magnetic resonance imaging of the thoracic spine. Evaluation of asymptomatic individuals. J Bone Joint Surg Am. Nov 1995;77(11):1631-8. [Medline]. [Full Text].
Schellhas KP, Pollei SR, Dorwart RH. Thoracic discography. A safe and reliable technique. Spine. Sep 15 1994;19(18):2103-9. [Medline].
Nannapaneni R, Marks SM. Posterolateral thoracic disc disease: clinical presentation and surgical experience with a modified approach. Br J Neurosurg. Oct 2004;18(5):467-70. [Medline].
Brown CW, Deffer PA Jr, Akmakjian J, Donaldson DH, Brugman JL. The natural history of thoracic disc herniation. Spine. Jun 1992;17(6 suppl):S97-102. [Medline].
Kaplan PA, Helms CA, Dussault R, Anderson MW, Major NM. Musculoskeletal MRI. Philadelphia, Pa: WB Saunders Company; 2001:279-332.
Wood KB, Schellhas KP, Garvey TA, Aeppli D. Thoracic discography in healthy individuals. A controlled prospective study of magnetic resonance imaging and discography in asymptomatic and symptomatic individuals. Spine. Aug 1 1999;24(15):1548-55. [Medline].
Boswell MV, Trescot AM, Datta S, et al, for the American Society of Interventional Pain Physicians. Interventional techniques: evidence-based practice guidelines in the management of chronic spinal pain. Pain Physician. Jan 2007;10(1):7-111. [Medline]. [Full Text].
Albrand OW, Corkill G. Thoracic disc herniation. Treatment and prognosis. Spine. Jan-Feb 1979;4(1):41-6. [Medline].
Arce CA, Dohrmann GJ. Herniated thoracic disks. Neurol Clin. May 1985;3(2):383-92. [Medline].
Bohlman HH, Zdeblick TA. Anterior excision of herniated thoracic discs. J Bone Joint Surg Am. Aug 1988;70(7):1038-47. [Medline]. [Full Text].
Broc GG, Crawford NR, Sonntag VK, Dickman CA. Biomechanical effects of transthoracic microdiscectomy. Spine. Mar 15 1997;22(6):605-12. [Medline].
Carson J, Gumpert J, Jefferson A. Diagnosis and treatment of thoracic intervertebral disc protrusions. J Neurol Neurosurg Psychiatry. Feb 1971;34(1):68-77. [Medline]. [Full Text].
Derby R, Chen Y, Lee SH, Seo KS, Kim BJ. Non-surgical interventional treatment of cervical and thoracic radiculopathies. Pain Physician. Jul 2004;7(3):389-94. [Medline]. [Full Text].
el-Kalliny M, Tew JM Jr, van Loveren H, Dunsker S. Surgical approaches to thoracic disc herniations. Acta Neurochir (Wien). 1991;111(1-2):22-32. [Medline].
Haro H, Domoto T, Maekawa S, et al. Resorption of thoracic disc herniation. Report of 2 cases. J Neurosurg Spine. Mar 2008;8(3):300-4. [Medline].
Hott JS, Feiz-Erfan I, Kenny K, Dickman CA. Surgical management of giant herniated thoracic discs: analysis of 20 cases. J Neurosurg Spine. Sep 2005;3(3):191-7. [Medline].
Krauss WE, Edwards DA, Cohen-Gadol AA. Transthoracic discectomy without interbody fusion. Surg Neurol. May 2005;63(5):403-8; discussion 408-9. [Medline].
Le Roux PD, Haglund MM, Harris AB. Thoracic disc disease: experience with the transpedicular approach in twenty consecutive patients. Neurosurgery. Jul 1993;33(1):58-66. [Medline].
Lesoin F, Rousseaux M, Autricque A, et al. Thoracic disc herniations: evolution in the approach and indications. Acta Neurochir (Wien). 1986;80(1-2):30-4. [Medline].
Maiman DJ, Larson SJ, Luck E, El-Ghatit A. Lateral extracavitary approach to the spine for thoracic disc herniation: report of 23 cases. Neurosurgery. Feb 1984;14(2):178-82. [Medline].
Mulier S, Debois V. Thoracic disc herniations: transthoracic, lateral, or posterolateral approach? A review. Surg Neurol. Jun 1998;49(6):599-606; discussion 606-8. [Medline].
Ohnishi K, Miyamoto K, Kanamori Y, Kodama H, Hosoe H, Shimizu K. Anterior decompression and fusion for multiple thoracic disc herniation. J Bone Joint Surg Br. Mar 2005;87(3):356-60. [Medline]. [Full Text].
Patterson RH Jr, Arbit E. A surgical approach through the pedicle to protruded thoracic discs. J Neurosurg. May 1978;48(5):768-72. [Medline].
Perez-Cruet MJ, Kim BS, Sandhu F, Samartzis D, Fessler RG. Thoracic microendoscopic discectomy. J Neurosurg Spine. Jul 2004;1(1):58-63. [Medline].
Perot PL Jr, Munro DD. Transthoracic removal of midline thoracic disc protrusions causing spinal cord compression. J Neurosurg. Oct 1969;31(4):452-8. [Medline].
Ransohoff J, Spencer F, Siew F, Gage L Jr. Transthoracic removal of thoracic disc. Report of three cases. J Neurosurg. Oct 1969;31(4):459-61. [Medline].
Regan JJ, Ben-Yishay A, Mack MJ. Video-assisted thoracoscopic excision of herniated thoracic disc: description of technique and preliminary experience in the first 29 cases. J Spinal Disord. Jun 1998;11(3):183-91. [Medline].
Rosenthal D, Rosenthal R, de Simone A. Removal of a protruded thoracic disc using microsurgical endoscopy. A new technique. Spine. May 1 1994;19(9):1087-91. [Medline].
Simpson JM, Silveri CP, Simeone FA, Balderston RA, An HS. Thoracic disc herniation. Re-evaluation of the posterior approach using a modified costotransversectomy. Spine. Oct 1 1993;18(13):1872-7. [Medline].
Stillerman CB, Chen TC, Couldwell WT, Zhang W, Weiss MH. Experience in the surgical management of 82 symptomatic herniated thoracic discs and review of the literature. J Neurosurg. Apr 1998;88(4):623-33. [Medline].
Stillerman CB, Weiss MH. Management of thoracic disc disease. Clin Neurosurg. 1992;38:325-52. [Medline].
Ulivieri S, Oliveri G, Petrini C, Voltolini L, Gotti G. Transmanubrial osteomuscolar sparing approach for T1-T2 thoracic disc herniation. Minerva Chir. Oct 2008;63(5):421-3. [Medline].
Wakefield AE, Steinmetz MP, Benzel EC. Biomechanics of thoracic discectomy. Neurosurg Focus. Sep 15 2001;11(3):E6. [Medline].
Wenger DR, Frick SL. Scheuermann kyphosis. Spine. Dec 15 1999;24(24):2630-9. [Medline].
Williams MP, Cherryman GR, Husband JE. Significance of thoracic disc herniation demonstrated by MR imaging. J Comput Assist Tomogr. Mar-Apr 1989;13(2):211-4. [Medline].
Wood KB, Blair JM, Aepple DM, et al. The natural history of asymptomatic thoracic disc herniations. Spine. Mar 1 1997;22(5):525-9; discussion 529-30. [Medline].
Further Reading
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
