American Journal of Physical Medicine & Rehabilitation:
Sari, Hidayet MD; Uludag, Murat MD; Gun, Kerem MD; Mogulkoc, Neslihan MD; Gokpinar, Hasan Huseyin MD
From the Department of Physical Medicine and Rehabilitation, İstanbul University Cerrahpasa Medical Faculty, Istanbul, Turkey.
All correspondence and requests for reprints should be addressed to: Murat Uludag, MD, Tahtakale Mah. T45 Sok. Bizimevler Sitesi A1 D27, Avcilar-İstanbul, Türkiye.
Financial disclosure statements have been obtained, and no conflicts of interest have been reported by the authors or by any individuals in control of the content of this article.
A 34-yr-old woman with back pain, right chest pain, and difficulty walking that started 15 days earlier while doing housework was evaluated. She reported that her household duties frequently including pushing and lifting heavy objects. Her physical examination revealed spasm of the thoracic and lumbar paravertebral muscles, hypalgesia below the T8 dermatome and decreased lower-limb muscle strength (Medical Research Council Grade 4/5). She had hyperactive reflexes at the knees and ankles, a positive Babinski sign, ankle clonus, and grade 2 spasticity (modified Ashworth scale), with no pathological findings in the upper limbs. She also reported urge incontinence.
Magnetic resonance imaging showed an extruded disk at T2–3, protruded disks at T3–4, T4–5, and T5–6 with mild spinal cord compression, and extruded disks at T7–8, T8–9, T9–10, and T10–11 with severe spinal cord compression (Fig. 1). Symptomatic multilevel thoracic disk herniations with myelopathy was diagnosed. Disk herniations were seen at eight of the 12 thoracic levels, and the extruded disks at T7–8 and T8–9 were thought to be symptomatic. The patient was referred for surgical intervention but preferred conservative management. She was subsequently lost to follow-up.
Thoracic disk herniation (TDH) occurs much less frequently than cervical or lumbar disk herniation, and multiple TDHs are rare. The symptoms and signs are usually slowly progressive and are not strongly associated with the herniated disk position, level, composition, or size.1
TDH accounts for only about 0.25%–0.75% of all symptomatic herniated disks and about 0.15%–1.8% of surgically treated disk herniations. Most TDHs are found in the lower thoracic spine, with more than 75% occurring below T8, mainly at T11–12, probably related to weakness of the posterior longitudinal ligament and the hypermobility of the lower thoracic segment.1,2
In a study of 78 cases of TDH, 26% of the patients had herniations at multiple levels, and 12% had disk protrusions at noncontiguous levels.3
A history of trauma is present in almost half of the patients, although the role of trauma in the pathogenesis of herniation is still not clear. The clinical presentation can be extremely varied, from no symptoms to symptoms mimicking those of other conditions such as lumbar disk herniation and cardiac, abdominal, gastrointestinal, neoplastic, and demyelinating diseases. Band-like dermatomal sensory disturbance, girdle pain, low back pain, motor weakness, or even symptoms of myelopathy can occur.1,2
Although uncommon and often asymptomatic, multiple TDHs can easily be misdiagnosed and should not be overlooked.
1. Chen CF, Chang MC, Liu CL, et al.: Acute noncontiguous multiple-level thoracic disc herniations with myelopathy: A case report. Spine (Phila Pa 1976). 2004; 29: E157–60.
2. Ohnishi K, Miyamoto K, Kanamori Y, et al.: Anterior decompression and fusion for multiple thoracic disc herniation. J Bone Joint Surg Br. 2005; 87: 356–60.
3. Linscott MS, Heyborne R.: Thoracic intervertebral disk herniation: A commonly missed diagnosis. J Emerg Med. 2007; 32: 235–8.