synonyms:Herniated Nucleus Propulsus, Thoracic Herniated Disc, thoracic HNP
Thoracic Herniated Disc ICD-9
Thoracic Herniated Disc Etiology / Epidemiology / Natural History
- Generally 4th-6th decade.
- Tumor necrosis factor-alph, produced by chondrocyte like cells in the nucleus pulposus may be the key chemical mediator for nerve root pain.
- Natural history: (Brown CD, Spine 1992;17:S97).
Thoracic Herniated Disc Anatomy
- Typically occur at T8-L1.
- Lateral herniations which only encroach on the nerve root are more likely to cause radicular symptoms.
- Midline and paramedian herniations are more likely to cause myelopathy.
Thoracic Herniated Disc Clinical Evaluation
- Subtle/vague complaints. Axial thoracolumbar spine pain.
- May have radicular pain radiating to the anterior chest wall in a dermatomal distribution.
- Sensory motor exam of the perineum including a rectal exam is indicated if any question of bowel/bladder dysfunction exists to rule out Cauda Equina Syndrome.
- Long Track signs indicate myelopathy
-Babinski's Reflex: upturning and splaying of the toes with plantar stimulus
-Hoffman's sign: flexion of the thumb and index fingers in response to flicking the tip of the outstretched middle finger
-Lhermitte's sign: shooting sensations down the arm with rapid neck flexion.
-Inverted Radial reflex: decreased brachioradialis reflex with concomitant flexion of all fingers.
Thoracic Herniated Disc Xray / Diagnositc Tests
- A/P, lateral, flexion/extensionviews of effected spinal level (cervical, lumbar, thoracic) indicated. Often normal or normal degenerative changes.
- MRI: best demonstrates acute herniation. Gadolinium enhancement indicated for patients with history of prior surgery. High prevalance of incidental disc herniations.
Thoracic Herniated Disc Classification / Treatment
- Short period of rest followed by activity limitations, NSAIDS, Physical therapy, muscle relaxants, Narcotics, progressive activity. Consider rigid brace .
- Surgical options: Anterior thoracotomy and decompression, video-assisten thorcospic surgery (Anand N, Spine 2002;27:871), transpedicular approach (soft lateral protrusions), costotransversectomy approach, lateral extracavitary approach.
Thoracic Herniated Disc Associated Injuries / Differential Diagnosis
- Herpes zoster
- Intercostal neuralgia
- Cauda Equina Syndrome
- Lumbar degenerative disc disease
- Lumbar spinal stenosis
Thoracic Herniated Disc Complications
Thoracic Herniated Disc Follow-up Care
Thoracic Herniated Disc Review References
- Vanichkachorn JS, JAAOS 2000;8:159