Complications
A herniated disc occurs when the intervertebral disc's annulus (the
outer fibers) is damaged and the soft inner material of the nucleus
pulposus ruptures out of its normal space. If the annulus tears near
the spinal canal, the nucleus pulposus material can push into the
spinal canal. There is very little extra space around the spinal cord
in the thoracic area. So when a herniated disc occurs in the mid back
it can be extremely serious. In severe cases, the pressure on the
spinal cord can lead to paralysis below the waist. Fortunately,
herniated discs are not nearly as common in the thoracic spine as in
the lumbar spine.
Learn about herniated thoracic disc including
- what causes a herniated thoracic disc
- how a diagnosis is made
- what treatment options are available
- what complications can arise
In order to understand your symptoms and treatment choices, it is
helpful to start with a basic understanding of the anatomy of the mid
back. Become familiar with the various parts that make up the thoracic
spine and how they work together.
Learn more about the anatomy of the thoracic spine.
The intervertebral discs are the shock-absorbing cushions between
each vertebra of your spine. There is one disc between each vertebra.
Each disc has a strong outer ring of fibers, called the annulus, and a
soft, jelly-like center, called the nucleus pulposus.
The annulus is the disc's outer layer and the strongest area of the
disc. The annulus is actually a strong ligament that helps connect each
vertebra together. The nucleus in the center of the disc serves as the
main shock absorber.
A herniated disc occurs when the intervertebral disc's outer fibers
(the annulus) are damaged and the soft inner material of the nucleus
pulposus ruptures out of its normal space. If the annulus tears near
the spinal canal, the nucleus pulposus material can push into the
spinal canal.
Herniated discs can occur in children, although it is rare. A true
herniated nucleus pulposus is most common in young and middle-aged
adults and generally occurs in the low back. Disc herniations in the
thoracic spine mostly affect people between age 40 and 60. In older
folks, the degenerative changes that occur in the spine with aging make
it less likely for them to suffer a true herniated disc.
Discs can rupture suddenly because of too much pressure all at once.
For example, falling from a ladder and landing in a sitting position
can cause a great amount of force through the spine. If the force is
strong enough, either a vertebra can break or a disc can rupture.
Bending places high forces on the discs between each vertebra. If you
bend and try to lift something that is too heavy, the force can cause a
disc to rupture.
Discs can also rupture from a small amount of force, usually due to
weakening of the annulus from repeated injuries that add up over time.
As the annulus becomes weaker, at some point lifting or bending causes
too much pressure across the disc. The weakened disc ruptures while
doing something that five years earlier would not have caused a
problem. This is due to the effects of aging on the spine-the most
common reason for a disc herniation in the thoracic spine.
The material that has ruptured into the spinal canal from the
nucleus pulposus can cause pressure on the nerves in the spinal canal.
There is also some evidence that the nucleus pulposus material causes a
chemical irritation of the nerve roots. Both the pressure on the nerve
root and the chemical irritation can lead to problems with how the
nerve root functions. The combination of the two can cause pain,
weakness, and numbness in the area of the body to which the nerve
supplies sensation.
In the thoracic spine, the pressure can also affect the spinal cord.
This is due to the fact that there is little extra space within the
spinal canal of the thoracic spine. Too much pressure on the spinal
cord can lead to paralysis from the waist down.
The first symptom of a thoracic disc herniation is usually pain. The
pain is most often felt in the back, directly over the sore disc. Pain
may also radiate around to the front of the chest. Pressure or
irritation on the nerves in the thoracic area can also cause symptoms.
Depending on which nerves are affected, a thoracic disc herniation can
include pain that feels like it is coming from the heart, abdomen, or
kidneys.
Herniated thoracic discs sometimes press against the spinal cord. When this happens, symptoms may include
- muscle weakness, numbness, or tingling in one or both legs
- increased reflexes in one or both legs that can cause spasticity
- changes in bladder or bowel function
- paralysis from the waist down
History and Physical Exam
Diagnosing a herniated nucleus pulposus begins with a complete history of the problem and a physical exam.
Your doctor will want to make sure that you are aware when you have
to urinate or have a bowel movement. If there is a problem, it could
indicate that a herniated disc in the thoracic spine is pushing against
the spinal cord.
Diagnostic Tests
X-rays
The doctor may suggest taking X-rays
of your mid back. Regular X-rays can't show a herniated disc, but they
can give your doctor an idea of how much wear and tear is present in
the spine. X-rays can also show a disc that has become calcified, as
often happens to a herniated thoracic disc. If part of the calcified
disc appears to be pointing into the spinal cord, it's a good
indication the thoracic disc is herniated.
MRI
The most common test to diagnose a thoracic herniated disc is the MRI
scan. This test is painless and very accurate. It is usually the
preferred test to do (after X-rays) if a herniated thoracic disc is
suspected.
CT Scan
Sometimes, the X-ray and MRI do not tell the whole story. Other tests may be suggested. A myelogram, usually combined with a CT scan, may be necessary to give as much information as possible.
A herniated disc does not necessarily mean that you will need to
undergo surgery. The treatment of a herniated disc depends on the
symptoms. If the symptoms are getting better, your doctor may suggest
watching and waiting to see if they go away. If they are getting
steadily worse, your doctor may be more likely to suggest surgery. Many
people, who initially have problems due to a herniated disc, find their
symptoms completely resolve over several weeks or months.
Conservative Treatment
Observation
You may not need any treatment other than watching to make sure that
the problem does not progress. If the pain is bearable and symptoms
from nerve or spinal cord pressure are not getting worse, your doctor
may just want to watch and wait.
Rest
If the pain is more severe, it may be necessary to take a few days
off from work and decrease your activities. Your doctor may also
prescribe a back brace to help limit movement around the injured disc.
After several days, you should begin to get moving. Start with a gentle
walking program and increase the distance you walk each day.
Pain medications
Depending on the severity of your pain, medications can be used to
help control it. Over-the-counter pain relievers, such as ibuprofen,
Tylenol(tm), and some of the newer anti-inflammatory medications, may
be helpful.
If these types of medications
do not control the pain, your doctor may prescribe stronger pain
pills-narcotic or non-narcotic pain medications. Narcotic pain
medications are very strong but also very addictive. Non-narcotic pain
medications are less addictive, but are somewhat less effective than
narcotics. Most physicians do not like to prescribe narcotics for more
than a few days or weeks. Learn more about medications used to treat
back pain.
Physical Therapy
If your condition is causing only mild symptoms and does not appear
to be getting worse, your doctor may have you work with a physical
therapist. A well-rounded rehabilitation program assists in calming
pain and inflammation, improving your mobility and strength, and
helping you do your daily activities with greater ease and ability.
In very mild cases, physical therapy offers ways to control symptoms
and enable you to improve without surgery. Treatments focus on
improving mobility and posture. Therapy sessions may be scheduled two
to three times each week for up to six weeks.
The goals of physical therapy are to help you
- learn ways to manage your condition and control the symptoms
- learn correct posture and body movements to reduce back strain
- identify symptoms of thoracic herniation that require medical attention
- learn ways to manage your condition
Learn more about spinal rehabilitation.
Surgical Treatment
Laminotomy and Discectomy
The traditional way of surgically treating a herniated thoracic disc
used to be to perform laminotomy and discectomy. The term laminotomy
means "make an opening in the lamina", and the term discectomy means
"remove the disc." The purpose of taking out a herniated thoracic disc
was to decompress the spinal cord or spinal nerves. But nerve problems
that occurred with this traditional method of decompression have led
many doctors to discontinue this form of surgery for disc herniations
in the thoracic spine.
Transthoracic Decompression
A new way to decompress the spinal cord or spinal nerves is a
technique called transthoracic decompression. Operating from the
patient's side, the doctor makes a small opening through the ribs and
works on the spine through the chest cavity. A minimal amount of the
vertebral body and problem disc are removed, taking pressure off the
spinal cord. Fusion surgery is sometimes needed right afterward if a
larger section of the vertebra has to be taken out.
Costotransversectomy
Pressure on the spinal cord from a herniated thoracic disc can also
be effectively treated using a surgical procedure called
costotransversectomy. The surgeon makes an incision through the back of
the spine. The ends of one or more nearby ribs are removed where they
join the spine. A section of the transverse process (the small bone on
the side of the vertebra) is taken off. This forms an opening for the
doctor to see the injured disc. The surgeon can then decompress the
spinal cord by locating and removing the disc material that has
ruptured into the spinal canal.
Video Assisted Thoracoscopy Surgery (VATS)
VATS is a new way to perform thoracic surgery. Only small incisions
are required. The thoracoscope is a small T V camera that is passed
through the chest cavity. Watching on a TV screen, the surgeon can see
and treat the herniated disc. Because the incisions are small, most
patients have an easier time recovering from the procedure.
Fusion
Fusion surgery joins two or more bones into one solid bone. The
medical term for this procedure is arthrodesis. If surgery on the
herniated thoracic disc requires removal of a large section of bone and
disc material, the section of spine may become loose or unstable. When
this happens it may be necessary to fuse the bones right above and
below the unstable section.
Bone graft material is used to get the unstable bones to grow
together. Rods, plates, and screws are commonly used to hold the bones
in place so the bone graft heals. Learn more about spinal fusion.
Like all surgical procedures, operations on the back may have complications.
Because the surgeon is operating around the spinal cord, back
operations are always considered extremely delicate and potentially
dangerous. Take time to review the risks associated with thoracic spine
surgery with your doctor. Make sure you are comfortable with both the
risks and the benefits of the procedure planned for your treatment.
Learn more about possible complications of spine surgery.
There are also possible complications specifically related to a thoracic disc herniation.
