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Herniated Nucleus Propulsus Thoracic S23.0XXA

Lower extremity Cutaneous Innervation

Spinal Cord Anatomy

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.
    -Clonus

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
  • Infection
  • Spondylosis
  • 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
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