Thoracic Discogenic Pain Syndrome Treatment & Management

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. ^{[13, 14, 15, 16, 17]}

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. ^[18]

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. ^[19] 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. ^[20] The surgeon’s familiarity with the particular approach must also be taken into consideration.

A study by Yoshihara et al compared in-hospital morbidity and mortality rates between anterior and nonanterior approach procedures for thoracic disc herniation. The study concluded that anterior approach procedures for thoracic disc herniation were associated with increased in-hospital morbidity and mortality rates, as well as increased health care burden, compared with nonanterior approach procedures. ^[21]

A retrospective study by Cummins et al that included 697 patients who underwent surgery for thoracic disc herniations found that anterior operations had significantly lower rates of neural injury than posterior operations (4.6% vs 11.4%). Neural deficit was associated with an increased length of hospital stay and a greater likelihood of discharge to a skilled nursing facility. ^[22]

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.

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.

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.

Return-to-play criteria following thoracic disc herniation or thoracic discogenic pain syndrome require the athlete to be free of signs or symptoms due to the original injury, to have full range of motion, to have normal strength and flexibility, and to have healthy sport-specific mechanics. Athletes must be aware of their own limitations, a concept that is particularly important for individuals gradually returning to a competitive level of activity after an injury.

Trauma and strain due to sport-related injuries or other causes is implicated in only 20% of patients with thoracic disc herniations. In many of these cases, a twisting or torsional movement is involved. Minimizing forces on the spine through the use of proper mechanics in specific sporting activities is important. Additionally, strengthening the dynamic stabilizers of the spine to counteract the significant forces exerted on the spine during certain athletic activities is also important.

Maintaining proper flexibility plays a significant role in the prevention of injury in athletes of all ages. Additionally, an improvement in aerobic fitness can increase blood flow and oxygenation to all tissues, including the muscles, bones, and ligaments of the spine. Aerobic conditioning is a reasonable addition to any rehabilitation and prevention program.