CHAPTER 42 • THORACIC AND LUMBAR SPINE 253- There is generally no typical presentation on history
or physical examination. - Herniations typically occur from the fourth to sixth
decades of life, they may also be found in children
(Errico, Stecker, and Kostuik, 1997). - The majority of herniations occur in the lower tho-
racic segments with 75% below T8 with 28% located
at T11–T12 (Errico, Stecker, and Kostuik, 1997).
•Pain when present, can vary in character and location,
possibly occurring in the thoracic or lumbar region,
and possibly radiating to the trunk anteriorly, the
groin, and the lower extremities. - Neurologic findings as described in the history and
physical examination section may be present. - Diagnosis is often made by a high clinical suspicion
based on examination and correlating this with diag-
nositic studies. - MRI is the most sensitive method for diagnosis of a
thoracic disc herniation. - CT with myelography may also be used to provide
information on bony structure, and in particular, if it
is anticipated that the patient will require surgical
intervention. - In situations where disc herniation is associated with
radicular pain only, conservative treatment may be
most appropriate. - Conservative treatment may include relative rest, anti-
inflammatory medications, and therapies (Errico,
Stecker, and Kostuik, 1997).
•Surgical intervention for thoracic disc herniations is
indicated when signs of myelopathy are present. - Once the disc is removed, fusion is often recom-
mended secondary to cases of kyphotic deformity
resulting from the surgery.
THORACIC DISCOGENIC PAIN
- As with other thoracic pain generators, thoracic disco-
genic pain is often poorly recognized.
•Patients who experience disc pain without radicular
symptoms and without true evidence of a disc hernia-
tion or a significant herniation can often be refractory
to conservative treatment. - Discography may be useful for determining the diag-
nosis; however, it does remain controversial as previ-
ously described.
•With discography typically three or four levels are
examined. - When conservative treatment fails, which may include
therapies for general conditioning and strengthening,
surgery utilizing discectomy and fusion may be a con-
sideration.
THORACIC SPINAL STENOSIS- Spinal stenosis may affect the central canal or lateral
recess or both, and may affect one or more spinal levels. - Stenosis may be secondary to congenital, develop-
mental or acquired mechanisms. - As with the other areas of the spine although much
less common than the cervical or lumbar spine, tho-
racic spinal stenosis is generally the result of degener-
ative changes that cause narrowing of the canal
thereby generating pain and neurologic symptoms
(Errico, Stecker, and Kostuik, 1997). - The most common cause of stenosis is degenerative
joint disease and this can be a result of any or all the
following: spur formation, disc disease, narrowing
intervertebral space, ligament or facet hypertrophy,
and subluxation. - There has been little published data on the treatment
of thoracic spinal stenosis. - In the lumbar spine, the L4–L5 level is most com-
monly affected followed by L3–L4, L2–L3, L5–S1,
and T12–L1. - Clinically, stenosis can lead to the syndrome of neu-
rogenic claudication (pseudoclaudication).
•Patients may complain of unilateral or bilateral pain
that radiates, paresthesias or weakness, pain that is
generally worse with standing or walking, and
improves with sitting, lying down, or with forward
flexion at the waist (the classically described shop-
ping cart syndrome). - By forward flexing at the waist the patient can
increase the anterior–posterior diameter of the spinal
canal and often find relief. - Extension will usually exacerbate the pain.
•Patients will often describe walking uphill as
easier than downhill, and find comfort in a fetal
position. - The diagnosis can often be confirmed with radi-
ographs, CT myelography, CT scan, MRI, and elec-
trodiagnostics.
•Treatment when there is progressive neurologic
deficit requires surgical intervention. - Otherwise conservative treatment utilizing non-
steroidal anti-inflammatory drugs (NSAIDs), and
therapy emphasizing strengthening the abdominal and
spinal musculature and flexion based exercise is most
appropriate.
SCHEURMANN’S DISEASE- Scheurmann’s disease may be a cause of back pain in
adolescents, most commonly affecting males.