Damage of thoracic intervertebral discs: causes, symptoms, diagnosis, treatment

Damage to the thoracic intervertebral discs is less common than damage to the lumbar and cervical discs. According to observations, they are more common in young people, especially athletes, but also in older people. The relative scarcity of these victims, the small familiarity of physicians with such injuries, the considerable difficulties in establishing the correct diagnosis lead to the fact that in an acute period the traumas of the injured are treated not for the damage to the intervertebral pectoral disk, but more often for bruises, suspected fractures or subluxations of the vertebral end of the ribs , "Stretching" of the ligamentous apparatus, and so on.

Only many months and even years after the trauma, after experiencing numerous and most diverse methods of treatment that have not benefited them, such patients go to specialized institutions in which a correct diagnosis is made. In some of the operated patients, the time of the former injury was remote from the moment of operative intervention by 4-7 years and even more.

Consequently, in practice, it is more often necessary to deal not with fresh injuries of the thoracic intervertebral discs, but with chronic injuries or their consequences.

[1], [2], [3]

Symptoms of damage to the thoracic intervertebral discs

Complaints of victims in recent cases usually come down to local pains that increase during movement, with a deep sigh, laughter, etc. These complaints are not specific and do not give cause for suspicion of damage to the thoracic intervertebral disc.

In the remote after the injury, the complaints are of a more definite nature and allow one to suspect the damage to the disk. They can be reduced to the presence of constant pain at the junction of the rib with a transverse process of the corresponding vertebra. The patient characterizes these pains as aching and gnawing, harassing him at rest and during movements. Characteristic symptoms of damage to the thoracic intervertebral discs - at the beginning of the movements or when the position changes, these pains leave the patient for a short period of time, and then return with the same intensity. The pain may disappear after the injured leopard takes a very bizarre posture, in which he can not stay for long. Pain can acquire a hint of burning, intensifying when swallowing, sighing, eating. Less often they take the character of intercostal neuralgia. These constant pains lead to the fact that quite young people become very irritable, do not believe in the possibility of cure, easily excitable or, conversely, apathetic, suffering from insomnia.

Complaints of pain in various shades and intensity may be compounded by complaints of weakness in the arm and leg or weakness in both legs, difficulty urinating and other complaints characteristic of irritation, compression of the anterior-lateral divisions of the spinal cord or ischemia of it.

An objective examination usually does not allow to identify any local specific symptoms, except local soreness and unconvincing limitation of movements. In cases that involve the interest of the spinal cord or its elements, more distinct objective changes are revealed in the form of a change in sensitivity, often accompanied by a gnperpathetic hue, the presence of sub-trophies and atrophy, symptoms of radicular compression, or symptoms characteristic of spastic te- or paraparesis. In some of our patients there were manifestations of amyotrophic lateral sclerosis.

Consequently, the symptoms of lesions of the thoracic intervertebral discs do not have typical and inherent only to this damage data, on the basis of which it would be possible to confidently put a clinical diagnosis. In all such cases, it is necessary to conduct the most thorough differential diagnosis with purely neurological or neurosurgical diseases, which may have similar symptoms.

Diagnosis of lesions of thoracic intervertebral discs

X-ray examination also does not allow to reveal reliable data. In younger cases, at the youngest, it is possible to detect some, sometimes very unconvincing decrease in the height of the intervertebral disc, the phenomenon of local arthrosis in the costal-vertebral articulation, and the presence of a small osteophyte. In older persons, there are age-related changes inherent in involuntary degenerative changes in the spine, which further complicate the recognition of local damage. The specificity of the thoracic intervertebral discs and the entire thoracic spine does not allow us to resort to functional spondylography.

It facilitates the diagnosis of the detection in the survey spondplograms of the presence of a single calcification of the pulpous core of the damaged disc.

Anterior pneumomyalography sometimes reveals a deformation of the anterior wall of the spinal canal. Contrastive discography may be useful only when examining the lower thoracic discs.

The clinical course of lesions of the thoracic intervertebral discs can occur in two main variants. The first variant is characterized by damage to one intervertebral disk, clinically manifested pain syndrome with the presence or absence of compression of the spinal cord elements.

In the second variant there is damage to several disks, usually manifested by pain syndrome, functional backbone inconsistency, the presence or absence of symptoms from the side of the spinal cord or its elements.

[4], [5], [6], [7], [8]

Treatment of injuries of the thoracic intervertebral discs

Conservative treatment of lesions of the thoracic intervertebral discs

Conservative treatment of lesions of the thoracic intervertebral discs is similar to the described conservative treatment of injuries of lumbar intervertebral discs. As a rule, all fresh injuries of the thoracic intervertebral discs are treated conservatively primarily because they are most often not diagnosed and proceed under the guise of bruises, "stretching", etc. If neurological symptoms occur in the acute period, then their appearance is attributed to hemorrhages, bruises, concussions. The question of surgical treatment is put much later, when under the influence of various conservative methods of treatment for a long time does not come a cure.

Operative treatment of injuries of the thoracic intervertebral discs

Indications for surgical treatment: pain syndrome; single lesion of the thoracic intervertebral disc, which proceeds with the phenomena of compression of the spinal cord; single lesion of the thoracic intervertebral disc without the phenomena of compression of the spinal cord or its elements, but with the phenomena of severe functional inconsistency of the spine; Multiple damage of thoracic intervertebral discs with pain syndrome and functional inconsistency of the spine in young people.

The task of the undertaken operative intervention is to eliminate the phenomena of compression of the spinal cord or its elements, to relieve the patient from pain and to stabilize the spine.

Depending on the presence of damage to one thoracic intervertebral disc or several disks, the technically assigned problem is solved differently. In the first case, the intervention is performed by the type of total discectomy and corpo- rodea, in the second - by the type of multiple discectomy and anterior spondylodesis. In practice, one has to deal with such cases when it is possible to localize the damaged intervertebral disk only roughly. In such cases, we use multiple discectomy in the area of the alleged damage to the disc.

Operative intervention is performed under endotracheal anesthesia.

Preoperative preparation of these patients consists of the measures described above when describing interventions on the thoracic spine with crespural access.

The position of the patient is similar to that given to the patient with transglyural access.

Technique of surgical intervention for single lesion of the thoracic disk

Right-sided Crespleural access, corresponding to the level of lesion, reveals the affected disc. The features and details of the technique for exposing the anterior sections of the thoracic vertebrae are set out above. This disc is easily determined by reducing its height. In doubtful cases it is necessary to resort to control radiography with marking. Using a thin and sharp chisel, a total resection of the affected disc is made together with the end plates of the adjacent vertebral bodies. The posterior sections of the intervertebral disc are removed with a bone spoon. In the intervertebral defect insert a spongy autograft, taken on the crest of the wing of the ilium. Since the height of the intervertebral defect is usually insignificant in the thoracic region, one should additionally remove a part of the contiguous surfaces of the bodies of adjacent vertebrae so that a rectangular groove is formed to a depth of 2/3 of the anterior-posterior diameter of the vertebral bodies. Its width is 1/3 of the width of the body of the vertebra, its height is 1-1.5 cm. The size and shape of the autograft correspond to the size and shape of this groove. Sew the front longitudinal ligament. The wound of the thoracic wall is sutured layer by layer. The drainage is left in the pleural cavity. The postoperative period is no different from the postoperative management of patients with interventions on the bodies of the thoracic vertebrae for damage to the vertebral bodies. After 3-4 months impose a plaster corset for a period of 3-6 months. By this time, usually comes the bone adhesion of blocked vertebrae.

Technique of surgical intervention for multiple lesions of thoracic discs

Right-sided Crespleural access, corresponding to the level of damage, reveals the anterior section of the spine at the right length. The anterior longitudinal ligament is dissected in the form of a sash and on the left base is folded to the left. Determine the level of damage and the level of necessary stabilization of the spine. This level is usually established on narrowed disks, a decrease in the height of the ventral parts of the vertebral bodies, and the presence of bone beak-shaped growths. If there is any difficulty in determining the level of stabilization, a radiography with labeling should be used. On the front surface of the vertebral bodies through the corresponding bodies and intervertebral discs, a groove with a width of up to 2-2.5 cm, a depth of 1.5-2 cm is cut with a chisel at the entire level, which is subject to bone-clastic fixation. A prerequisite is that the groove ends in areas of vertebral bodies located above and below the extreme damaged discs. Through the formed groove with a bone spoon, remove the remains of all the discs opened. The bone-spongy autograft taken from the upper metaphysis of the tibia is placed in the formed groove, along the length, width and thickness corresponding to the size of the groove. In view of the fact that usually the thoracic spine is in the position of kyphosis, the depth of the groove in its terminal areas should be somewhat larger than in its middle section. Then the graft will evenly plunge into the groove and will lie flat against its walls evenly throughout. Over the groove, a flap of the anterior longitudinal ligament is laid and hemmed. The wound of the breast wall is layer-by-layer closed.

The postoperative period is the same as for interventions for single lesion of the thoracic disc.