Thoracic Discogenic Pain Syndrome Workup

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

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. See the image below.

Sagittal magnetic resonance image of a lower thoraSagittal 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 follows[8] :

  • 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.

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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.

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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.

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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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