Thoracic Discogenic Syndrome

Symptomatic thoracic discogenic syndrome poses a diagnostic challenge due to its rarity. The relative immobility of the thoracic spine due to its particular orientation, structure, and function in the vertebral column contributes to the rarity of thoracic discogenic syndrome. At birth, the thoracic spine and sacrum exhibit a kyphotic curvature, whereas the cervical and lumbar spine develop full lordosis around puberty. The lordotic nature of the cervical and lumbar spine enables them to bear most of the axial skeleton's weight compared to the thoracic and sacral spine. As a result, the latter regions are less prone to disk degeneration and subsequent discogenic pain syndromes. Except for the atlas and axis, between each vertebral body lies an intervertebral disk. These disks consist of the outer rigid fibrous ring, known as annulus fibrosis, an inner soft gelatinous core called the nucleus pulposus, and the vertebral endplates. The vertebral endplates lie on the superior and inferior aspects of the disks next to the vertebral bodies and aid in the diffusion of nutrients into the disks. The intervertebral disks absorb shock and allow flexibility of the vertebral column. As the body ages, the integrity of these disks declines, potentially leading to the protrusion of the nucleus pulposus through the outer layer. Affected patients may experience corresponding nerve root or spinal cord compression, leading to radicular or myelopathic symptoms. Although degeneration is the primary cause of thoracic disk disease, trauma accounts for a small percentage of injuries to this area. Patients may either remain asymptomatic or present with pain that can progress to radiculopathy or myelopathy. Many of the symptoms are nonspecific, and the pain is highly dependent on the location of the herniated disk. Patients may experience pain in various regions, such as the chest wall, epigastric area, upper extremities, groin, or lower extremities, leading to a broad range of differential diagnoses. Confirmation of the diagnosis is made using magnetic resonance imaging (MRI). Asymptomatic thoracic disk herniations are common incidental findings on MRI scans. The mainstay of therapy for thoracic discogenic pain syndrome is conservative, with a focus on posture, body mechanics, muscle strengthening, and prevention. Surgical intervention becomes necessary in cases where patients exhibit myelopathic signs or when severe pain persists despite conservative treatment measures. However, performing a diskectomy in the thoracic spine presents unique challenges. The spinal canal is relatively narrow in the thoracic spine, and the thecal sac cannot be manipulated as freely as it can within the lumbar region. Therefore, the operative approach must minimize manipulation of the dura and spinal cord. Various procedures are available, each with its advantages and disadvantages.