Thoracic disc herniation — prolapse of the thoracic intervertebral disc, normally not extending beyond the boundaries of the vertebral bodies. It is manifested by pain and sensitivity disorder of the chest, weakness in the lower extremities with pelvic dysfunction, various functional changes on the part of somatic organs. It is diagnosed according to MRI of the spine with the obligatory exception of pathology of internal organs. Conservative treatment includes medication and physiotherapy methods, manual therapy or spinal traction, physical therapy, massage. The operation involves deleting the disk.
General information
Thoracic disc herniation is much less common than intervertebral hernia of the lumbar region and hernia of the cervical region. According to some estimates, thoracic hernias account for no more than 1% of all intervertebral hernias, although there is no exact data on their prevalence, since in some cases they are characterized by an asymptomatic subclinical course. Mostly young and middle-aged people get sick. The most frequently observed lesion of the intervertebral discs of the lower thoracic spine (Th8-Th12). Depending on the localization, clinical manifestations of a thoracic hernia can mimic the symptoms of various pathologies of the chest and upper abdominal cavity organs. In this regard, their differential diagnosis should cause special alertness in the neurologist and be carried out with the involvement of specialists of other profiles: gastroenterologist, cardiologist, nephrologist, pulmonologist.
Causes
The main etiofactors of the occurrence of thoracic disc herniation are spinal injuries and osteochondrosis. In young patients, the formation of a hernia is caused either by trauma or by the early development of degenerative changes in the intervertebral discs. In patients over 40 years of age, hernias are usually a complication of osteochondrosis.
Traumatic injuries to the thoracic discs can occur with spinal contusion, vertebral subluxation, fracture of the thoracic spine, excessive load on the thoracic region when performing physical exercises or lifting weights. Chronic injury to the discs, leading to their premature degeneration and wear, is usually caused by working in an uncomfortable position (for example, surgeons, auto repairers, welders, tailors). Early development of osteochondrosis in the thoracic spine is often associated with an uneven load on the vertebral column with impaired posture or curvature of the spine (kyphosis, scoliosis), dysmetabolic processes in the body (diabetes mellitus, early menopause).
Injuries to the disc cause the formation of cracks in its fibrous ring. Degenerative processes, accompanied by a decrease in the hydrophilicity and elasticity of the disc, also lead to this. As a result of tears of the fibrous ring, the disc ceases to be held strictly between the vertebral bodies, part of it prolapses from the intervertebral space. There is a protrusion of the disc, which, with progression, develops into a herniated disc that increases in size. The main clinical manifestations of the latter are associated with its effect on the spinal nerve root and/or on the substance of the spinal cord itself.
Symptoms
In neurology, a thoracic disc herniation is classified into central and lateral. In the first case, the hernia manifests symptoms of compression of the spinal cord — compression myelopathy with the development of lower mono- or paraparesis, pelvic disorders. Due to the fact that discogenic myelopathy in the thoracic region is caused by compression of the conductive motor pathways, paresis is of a central (spastic) nature. Lateral hernia debuts with signs of irritation and compression of the corresponding spinal root — pain syndrome (radiculitis) and sensitive disorders in the chest area. As part of the spinal nerves of the thoracic region, visceral branches go to many internal organs: trachea, lungs, bronchi, esophagus, liver, 12 duodenum, gallbladder, kidneys. Therefore, a thoracic hernia may be accompanied by functional disorders of the corresponding visceral organs. The localization of these symptoms depends on the level of the location of the hernia, and therefore the division of thoracic hernias into upper, middle and lower is accepted.
Hernia of the upper thoracic region (Th1-Th4) is manifested by pain (thoracalgia) and paresthesia in the upper parts of the chest, the interscapular region. Thoracalgia in the left half can simulate an angina clinic. Hernia at the Th1-Th2 level is accompanied by paresthesia and weakness in the hands, numbness of the hands. Possible disorder of esophageal peristalsis, difficulty swallowing.
Hernia of the middle thoracic region (Th5-Th8) often occurs with symptoms of intercostal neuralgia — single or bilateral shingles along the intercostal spaces, resembling herpes zoster, but not accompanied by vesicular rashes. Such pains can limit the respiratory excursion of the chest with the formation of more shallow and rapid breathing. Possible pain in the stomach area. In some cases, a thoracic hernia can cause dyspepsia, enzyme insufficiency of the pancreas, disorders of insulin secretion, disorders in carbohydrate metabolism.
Hernia of the lower thoracic region (Th9-Th12) occurs with pains localized in the kidney area, under the ribs, in the upper abdomen, sometimes simulating an “acute abdomen”. Right—sided pains in the hypochondrium can be mistaken for manifestations of liver pathology, acute cholecystitis or appendicitis, shingling intense pain – for acute pancreatitis. A hernia at the Th11-Th12 level can provoke intestinal dyskinesia.
Diagnostics
Depending on the location and clinic of a thoracic hernia, patients often first turn to a therapist, cardiologist, gastroenterologist, urologist. However, an attentive clinician by the nature of the pain syndrome (increased movement, soreness during palpation of the thoracic spine, tension of the paravertebral muscles) may suspect spinal pathology. In such cases, lung x-ray allows you to definitively exclude pneumonia, pleurisy, tumor; ECG and ultrasound of coronary vessels — coronary heart disease; esophagogastroduodenoscopy and ultrasound of the abdominal cavity — gastrointestinal pathology; urine analysis, kidney ultrasound and urography — glomerulonephritis, urolithiasis, pyelonephritis.
Radiography of the spine allows you to diagnose osteochondrosis, deformities, post-traumatic changes. CT of the spine visualizes hernial protrusion, but does not make it possible to correctly assess its size and the degree of spinal compression. Therefore, the optimal diagnostic method is an MRI of the spine in the thoracic region. MRI more accurately determines the localization and volume of the hernia, allows you to assess the degree of inflammatory changes and spinal compression, to identify / exclude other diseases of the spine (spinal cord tumor, hematoma, spinal cord neurinoma, thoracic spondylosis, etc.). If MRI studies are contraindicated to the patient, then resort to the use of CT with myelography.
Treatment
Conservative treatment is aimed at relieving inflammation and pain, stopping the increase in hernia size, restoring lost neurological functions. Anti-inflammatory drugs are prescribed (naproxen, ibuprofen, ketoprofen, carprofen, etc.). Local administration of anesthetics and corticosteroid pharmaceuticals in the form of paravertebral blockades is performed. In the presence of spastic syndrome, muscle relaxants (tolperizone) are indicated. A course of treatment with vitamins B1 and B6 has a positive effect.
Some types of physiotherapy have an anti-inflammatory and muscle relaxant effect, for example, hydrocortisone ultraphonophoresis, electrophoresis, magnetotherapy, UHF. To relieve paravertebral muscle spasm, myofascial massage is prescribed. Manual therapy and traction therapy help to increase the distance between the vertebrae and thereby relieve pressure on the affected disc. The patient should follow a special regime, more strict in the acute period and excluding excessive loads on the spine in the future. With positive results of conservative measures, in order for the hernia symptoms not to return again, it is necessary to regularly perform a special complex of physical therapy aimed at creating a muscular corset that holds the spine.
Surgical treatment is indicated if a thoracic disc herniation does not respond to conservative therapy, symptoms of myelopathy occur, compression of the spinal root progresses. Urgent decompression of the spinal canal is performed by laminectomy. Depending on the size of the hernial protrusion, endoscopic microdiscectomy, microdiscectomy, discectomy can be performed. After the disc is removed, connective tissue growths that form the fusion of two vertebrae (ankylosis) take its place. It is necessary to approach the issue of the need for surgery as carefully as possible, since it can have a number of serious complications: bleeding, damage to spinal nerves, infection with the development of myelitis, spinal arachnoiditis, injury to the dura mater.
