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?
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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 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.
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Cord compression is present with myelopathy, which requires immediate attention. [2] (See also the 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)
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High thoracic (T2-T5) herniation mimics cervical disc disease. (See also the article Cervical Disc Disease.)
Patients can present with upper extremity involvement, including Horner syndrome. (See also the 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.
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Radicular symptoms include pain/paresthesias or dysesthesias in a dermatomal distribution. Dermatome T10 is usually involved.
Physical Examination
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.
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Palpation
Palpate the entire region of the thoracic spine.
Muscle spasms can be identified by palpation.
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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.
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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.
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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.
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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.
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Vascular examination of the dorsalis pedis artery, posterior tibial artery, and femoral artery can rule out other causes of the patient's symptoms.
