Thoracic discogenic pain syndrome may be radicular or myelopathic pain. The radicular pain is mostly secondary to posterolateral herniations that compress spinal nerves as they exit through the intervertebral foramen.
Symptomatic thoracic discogenic pain syndrome (TDPS) is a rare phenomenon making it challenging to diagnose. The rarity of TDPS is attributed to the particular orientation, structure, and function of the thoracic spine in the vertebral column. The thoracic spine and sacrum exhibit kyphosis which is present at birth, while the cervical and lumbar spine exhibit fully developed lordosis around puberty[rx]. The lordotic nature of the cervical and lumbar spine allows the imaginary line of gravity to run through, allowing them to bear most of the weight of the axial skeleton as compared to the thoracic and sacral spine[rx]. Consequently, they are subject to a higher percentage of degenerated discs and subsequent discogenic pain syndrome.
Causes of Thoracic Discogenic Pain Syndrome
Intervertebral disc degeneration primarily causes thoracic discogenic pain syndrome. The exact cause of disc degeneration is believed to be multifactorial. Factors that cause disc degeneration include trauma, metabolic abnormalities, genetic predisposition, vascular problems, and infections[rx]. Among these factors, trauma happens to be one of the most common causes of thoracic disc herniation. The effects of trauma as previously mentioned are less devasting on the thoracic spine as compared to the cervical and lumbar spine because the thoracic spine participates in less weight-bearing activities and the rib cage and coronal orientation of the facet joints make it more stable, hence less prone to degenerative disc disease. With trauma, chronic overload from the lifting of heavy objects or chronic multi-trauma from individuals participating in sports leads to the repeated rotation of the axial spine, causing vertebral instability with alteration of the spinal alignment that accelerates the risk of developing disc degeneration[rx][rx].
- A sudden sprain or strain (as in car accidents or sports injuries).
- Sitting or standing in a slouched position over time.
- Using a backpack.
- Sitting for a long time at a computer.
- Lack of muscular strength (couch potatoes beware!).
- Repeating a movement persistently that involves the thoracic part of the spine (as in sport or work): also called overuse injury.
- Narrowing of part of the spine (thoracic stenosis) – usually due to wear and tear.
- Slipped discs – these are common but rarely cause pain.
- Fractures of the vertebrae (the bony components that make up the spine).
- Osteoporosis.
- Spinal infection.
- Shingles (especially in people aged over 60 years).
- Spinal osteoarthritis.
- Ankylosing spondylitis – inflammation of the joints between the vertebrae.
- Scheuermann’s disease – an inflammation of the joints of the spine which results in spinal curvature.
- Spinal tumors.
It shouldn’t be assumed that all pain in the thoracic spine is coming from the spine itself. Other causes of pain in this area can include problems affecting the lung, the uppermost part of the gut (the esophagus), the stomach, the gallbladder, and the pancreas.
Symptoms of Thoracic Discogenic Pain Syndrome
- The patient may present with lower extremity numbness and weakness, pain, gait abnormalities, hyperreflexia, and in rare cases paraplegia.
- Recent serious injury, such as a car accident or a fall from a height.
- Minor injury or even just heavy lifting in people with ‘thinning’ of the bones (osteoporosis).
- Age under 20 or over 50 years when the pain first starts.
- A history of cancer, drug misuse, HIV infection, a condition that suppresses your immune system (immunosuppression), and use of steroids for a long time (about six months or more).
- Feeling generally poorly – for example, a high temperature (fever), chills, and unexplained weight loss.
- A recent infection by a germ (bacterial infection).
- Pain that is there all the time, severe and getting worse.
- Pain that wasn’t caused by a sprain or strain (non-mechanical).
- Pain that doesn’t get better after 2-4 weeks of treatment.
- Pain that is accompanied by severe stiffness in the morning.
- Changes to the shape of the spine, including the appearance of lumps or bumps.
- Pins and needles, numbness or weakness of the legs that is severe or gets worse over time.
- Passing wee or poo accidentally (can indicate pressure on the spinal cord).
Diagnosis of Thoracic Discogenic Pain Syndrome
A physical exam for diagnosing disc pain may include one or more of the following tests
- Palpation – Palpating (feeling by hand) certain structures can help identify the pain source. For example, worsened pain when pressure is applied to the spine may indicate sensitivity caused by a damaged disc, thoracic discogenic pain syndrome, diffuse idiopathic skeletal hyperostosis, and disc desiccation.
- Movement tests – Tests that assess the spine’s range of motion may include bending the neck or torso forward, backward, or to the side. Additionally, if raising one leg in front of the body worsens leg pain, it can indicate a thoracic discogenic pain syndrome
- Muscle strength – A neurological exam may be conducted to assess muscle strength and determine if a nerve root is compressed by thoracic discogenic pain syndrome. A muscle strength test may include holding the arms or legs out to the side or front of the body to check for tremors, muscle atrophy, or other abnormal movements.
- Reflex test – Nerve root irritation can dampen reflexes in the arms or legs. A reflex test involves tapping specific areas with a reflex hammer. If there is little or no reaction, it may indicate a compressed nerve root in the spine, disc desiccation.
- Physical examination – should include assessment of sensation with pinprick and touch in the upper extremity, thorax, and abdomen in the dermatomal regions mentioned above to check for radiculopathy and also in the lower extremity to check for myelopathy. Also, for the lower extremity, proprioception and reflexes and toned should be evaluated.
Lab Test
- A medical history – in which you answer questions about your health, symptoms, and activity.
- A physical exam to assess your strength – reflexes, sensation, stability, alignment, and motion. You may also need blood tests.
- Laboratory testing – may include white blood cell (WBC) count, erythrocyte sedimentation rate (ESR), and C-reactive protein (CRP).
- Elevated ESR – could indicate infection, malignancy, chronic disease, inflammation, trauma, or tissue ischemia.
- Elevated CRP – levels are associated with infection.
Imaging
- X-rays – view the bony vertebrae in your spine and can tell your doctor if any of them are too close together or whether you have arthritic changes, bone spurs, diffuse idiopathic skeletal hyperostosis, thoracic discogenic pain syndrome, or fractures narrowing of the spinal canal. It’s not possible to diagnose diffuse idiopathic skeletal hyperostosis, thoracic discogenic pain syndrome, disc desiccation with paracentral disc herniation in this test alone.
- Magnetic Resonance Imaging (MRI) scan – is a noninvasive test that uses a magnetic field and radiofrequency waves to give a detailed view of the soft tissues of your spine with thoracic discogenic pain syndrome, diffuse idiopathic skeletal hyperostosis, and paracentral disc herniation. Unlike an X-ray, nerves and discs are clearly visible. It may or may not be performed with a dye (contrast agent) injected into your bloodstream. An MRI can detect which disc is damaged and if there is any nerve compression disc desiccation, diffuse idiopathic skeletal hyperostosis. It can also detect bony overgrowth, spinal cord tumors, abscesses, or narrowing of the spinal canal.
- A myelogram – is a specialized X-ray where dye is injected into the spinal canal through a spinal tap. An X-ray fluoroscope then records the images formed by the dye. The dye used in a myelogram shows up white on the X-ray, allowing the doctor to view the spinal cord and canal, thoracic discogenic pain syndrome, a bulging disc paracentral disc herniation, disc desiccation in detail. Myelograms can show a nerve being pinched and a bulging disc by a herniated disc, bony overgrowth, narrowing of the spinal cord tumors, disc desiccation, thoracic discogenic pain syndrome, and abscesses.
- Computed Tomography (CT) scan – is a noninvasive test that uses an X-ray beam and a computer to make 2-dimensional images of your spine. It may or may not be performed with a dye (contrast agent) injected into your bloodstream. This test is especially useful for confirming which bulging disc and narrowing of the spinal canals are damaged, thoracic discogenic pain syndrome.
- Electromyography (EMG) & Nerve Conduction Studies (NCS) – EMG tests measure the electrical activity of your muscles. Small needles are placed in your muscles, and the results are recorded on a special machine. NCS is similar, but it measures how well your nerves pass an electrical signal from one end of the nerve to another. These tests can detect nerve damage and muscle weakness and a bulging disc, disc desiccation, thoracic discogenic pain syndrome, paracentral disc herniation.
- Discogram – A discogram may be recommended to confirm which bulging disc is painful if surgical treatment is considered. In this test, the radiographic dye is injected into the disc to recreate disc pain from the dye’s added pressure. Electrodiagnostic evidence of fibrillation potentials and the absence of a tibial H-wave may aid in further confirming the diagnosis of lumbar canal stenosis, thoracic discogenic pain syndrome, and disc desiccation.[rx]
Treatment of Thoracic Discogenic Pain Syndrome
Non-Pharmacological
- Exercise and physical therapy – These are essential for getting back pain under control and improving stiffness and range of motion. Swimming is especially beneficial because it provides a full-body workout without the risk of injury. Physical therapy can reduce the stiffness associated with thoracic discogenic pain syndrome. Exercises might also increase the range of motion in your joints. Ask your doctor about specific exercises you can do. He or she might refer you to a physical therapist for further guidance.
- Heat – This can help relieve early-morning pain and stiffness.
- Weight and blood sugar control – Because thoracic discogenic pain syndrome is often associated with obesity and diabetes, keeping your weight and blood sugar in a healthy range is key. Treating these conditions is the closest thing to a cure for thoracic discogenic pain syndrome.
- Orthotics (special shoe inserts) – These may make walking easier if you have bone spurs on your thoracic discogenic pain syndrome.
- Stay hydrated – Not drinking enough water each day can cause the body to function less well or not retain enough water, including the discs, thoracic discogenic pain syndrome, and diffuse idiopathic skeletal hyperostosis.
- Don’t smoke – Cigarette use can directly affect the discs in the back and increase the rate of disc degeneration, thoracic discogenic pain syndrome.
- Maintain a healthy weight – Being overweight or obese puts extra pressure on the back and spine, which can cause desiccation, thoracic discogenic pain syndrome, and decay of the intervertebral discs.
- Take regular exercise – Participating in regular cardio and weight-training exercises can strengthen the bones and muscles and promote a good range of motion in the back. People can ask their doctor or a physical therapist for specific exercises that support the back muscles.
- Spine-Specialized physical therapy – typically includes a combination of stretching, strengthening, and aerobic exercise to provide better stability and support for the spine.
- Massage therapy – can help reduce muscle tension and muscle spasms, which may add to back or neck pain. Muscle tension is especially common around an unstable spinal segment where a disc is unable to provide the necessary support
- Ice & Moist Heat Application – Ice application where the ice is wrapped in a towel or an ice pack for about 20 minutes to the affected region, thrice a day, helps in relieving the symptoms of a disc bulge. Heat application in the later stages of treatment also provides the same benefit.
- Use of lumbosacral back support – Generally, back braces are categorized as flexible, semi-rigid, and rigid. Rigid braces tend to be used for moderate to severe cases of pain and/or instability, such as to assist healing of spinal fractures or after back surgery. Semi-rigid and flexible braces are used for more mild or moderate pain.
- Eat Nutritiously During Your Recovery – All bones and tissues in the body need certain nutrients in order to heal properly and in a timely manner. Eating a nutritious and balanced diet that includes lots of minerals and vitamins is proven to help heal back pain of all types of lumbar disc disease, thoracic discogenic pain syndrome. Therefore focus on eating lots of fresh produce (fruits and veggies), whole grains, lean meats, and fish to give your body the building blocks needed to properly healing PLID, and narrowing of the spinal canal. In addition, drink plenty of purified water, milk, and other dairy-based beverages to augment what you eat.
- In bulging disc needs ample minerals (calcium, phosphorus, magnesium, boron) and protein to become strong and healthy again.
- Excellent sources of minerals/protein include dairy products, tofu, beans, broccoli, nuts and seeds, sardines, and salmon.
- Important vitamins that are needed for bone healing include vitamin C (needed to make collagen), vitamin D (crucial for mineral absorption), and vitamin K (binds calcium to bones and triggers collagen formation).
- Conversely, don’t consume food or drink that is known to impair bone/tissue healing, such as alcoholic beverages, sodas, most fast food items, and foods made with lots of refined sugars and preservatives.
Medications
- Analgesics – Such as paracetamol and prescription-strength drugs that relieve pain but not inflammation.
- Muscle Relaxants – These medications provide relief from spinal muscle spasms. Muscle relaxants, such as baclofen, tolperisone, eperisone, methocarbamol, carisoprodol, and cyclobenzaprine, may be prescribed to control muscle spasms.
- Neuropathic Agents – Drugs(pregabalin & gabapentin) that address neuropathic—or nerve-related—pain. This includes burning, numbness, and tingling.
- Opioids – Also known as narcotics, these medications are intense pain relievers that should only be used under a doctor’s careful supervision.
- NSAIDs – Prescription-strength drugs that reduce both pain and inflammation. Pain medicines and anti-inflammatory drugs help to relieve pain and stiffness, allowing for increased mobility and exercise. There are many common over-the-counter medicines called non-steroidal anti-inflammatory drugs (NSAIDs). They include mainly or first choice etodolac, then aceclofenac, etoricoxib, ibuprofen, and naproxen.
- Calcium & vitamin D3 – To improve bone health and healing fracture. As a general rule, men and women age 50 and older should consume 1,200 milligrams of calcium a day, and 600 international units of vitamin D a day.
- Glucosamine & Diacerein, Chondroitin sulfate – can be used to tightening the loose tendon, cartilage, ligament, and cartilage, ligament regenerates cartilage or inhabits the further degeneration of cartilage, ligament.
- Dietary supplement – to remove general weakness & improved health.
- Vitamin B1, B6, and B12 – It is essential for neuropathic pain management, pernicious anemia, with vitamin b complex deficiency pain, paresthesia, numbness, itching with diabetic neuropathy pain, myalgia, etc.
- Antidepressants – A drug that blocks pain messages from your brain and boosts the effects of endorphins (your body’s natural painkillers).
- Oral Corticosteroid – to healing the nerve inflammation and clotted blood in the joints. Steroids may be prescribed to reduce the swelling and inflammation of the nerves. They are taken orally (as a Medrol dose pack) in a tapering dosage over a five-day period. It has the advantage of providing almost immediate pain relief within a 24-hour period.
- Topical Medications – These prescription-strength creams, gels, ointments, patches, and sprays help relieve pain and inflammation throughout the skin.
- Steroid injections The procedure is performed under x-ray fluoroscopy and involves an injection of corticosteroids and a numbing agent into the epidural space of the spine. The medicine is delivered next to the painful area to reduce the swelling and inflammation of the nerves. About 50% of patients will notice relief after an epidural injection, although the results tend to be temporary. Repeat injections may be given to achieve the full effect. Duration of pain relief varies, lasting for weeks or years. Injections are done in conjunction with physical therapy and/or a home exercise program.
- epidural steroid injection. A steroid solution is injected into the epidural space (outer layer of the spinal canal) to reduce inflammation. This injection is by far the most common one used for herniated discs.
- Selective nerve root injection. A steroid solution and anesthetic are injected near the spinal nerve as it exits through the intervertebral foramen. This injection is also used to help diagnose which nerve root might be causing pain.
Surgery
Surgical intervention is considered as a last resort for the treatment of symptomatic thoracic disc herniations with patients unresponsive to conservative treatment. Surgery will allow for the removal of the ossified disc decompressing the region and relieving pressure on the nerve or spinal cord. Despite advances in thoracic disc herniation surgery, there are still about 20% to 30% complications associated with it[rx][rx]. Several factors contribute to these complications. First, symptomatic thoracic disc herniation is rare making it difficult for doctors to gain enough experience to handle it. Secondly, the nature of the thoracic spines makes it difficult to access the herniations. For example, accessing herniations that are located centrally and anteriorly via the posterior vertebral column will mean manipulating the thoracic spine that may result in further spinal cord injury and neurological deficits[rx][rx]. Accessing centrally located herniations through the anterior transthoracic approach provides an optimal corridor but is also involved high complications and mortalities[rx]. Thirdly, herniations that are calcified and adherent to the dura risk dural tear during surgery leading to CSF leak and intracranial and orthostatic hypotension and headache[rx][rx].
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