Thoracic intervertebral disc injuries: 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 they also occur in older people. The relative rarity of these victims, the poor familiarity of doctors with such damage, and the significant difficulties in making a correct diagnosis lead to the fact that in the acute period of injury, victims are treated not for damage to the thoracic intervertebral disc, but more often for bruises, suspected fractures or subluxations of the vertebral end of the ribs, "stretches" of the ligamentous apparatus, etc.

Only many months and even years after the injury, having tried numerous and most diverse methods of treatment that did not bring them any benefit, such patients are admitted to specialized institutions where the correct diagnosis is made. In some of the operated patients, the moment of the former injury was 4-7 years or even more distant from the moment of the surgical intervention.

Consequently, in practice, one often has to deal not with fresh damage to the thoracic intervertebral discs, but with old damage or its consequences.

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Symptoms of thoracic intervertebral disc damage

Complaints of victims in recent cases usually come down to local pain, which intensifies with movement, deep breathing, laughter, etc. These complaints are not specific and do not give reason to suspect damage to the thoracic intervertebral disc.

At a later stage after the injury, complaints are more specific and allow one to suspect damage to the disc. They can be reduced to the presence of constant pain at the junction of the rib with the transverse process of the corresponding vertebra. The patient describes these pains as aching and gnawing, tormenting him at rest and during movements. Characteristic symptoms of damage to the thoracic intervertebral discs - at the beginning of movements or when changing position, these pains leave the patient for a short period, and then return with the same intensity. The pains can disappear after the victim takes a very bizarre pose, in which he cannot remain for a long time. The pains can acquire a burning tint, increasing with swallowing, inhaling, eating. Less often, they take on 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 recovery, easily excitable or, conversely, apathetic, suffering from insomnia.

Complaints of pain of various shades and intensities may be accompanied 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 anterolateral parts of the spinal cord or its ischemia.

An objective examination usually does not reveal any local specific symptoms, except for local soreness and unconvincing limitation of movements. In cases accompanied by involvement of the spinal cord or its elements, more distinct objective changes are revealed in the form of changes in sensitivity, often accompanied by a hyperpathic shade, the presence of subatrophy and atrophy, symptoms of radicular compression or symptoms characteristic of spastic te- or paraparesis. In some of our patients, manifestations of amyotrophic lateral sclerosis were observed.

Consequently, the symptoms of thoracic intervertebral disc injuries do not have typical and specific data for this injury, on the basis of which a clinical diagnosis could be confidently made. In all such cases, it is necessary to conduct the most careful differential diagnosis with purely neurological or neurosurgical diseases, which may have similar symptoms.

Diagnosis of thoracic intervertebral disc injuries

X-ray examination also does not reveal reliable data. In younger victims, at best, it is possible to detect some, sometimes very unconvincing, decrease in the height of the intervertebral disc, local arthrosis in the costovertebral joint, and the presence of a small osteophyte. In older individuals, there are age-related changes characteristic of involutional 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 resorting to functional spondylography.

The detection of a single calcification of the nucleus pulposus of the damaged disc on general spondylograms facilitates diagnosis.

Anterior pneumomyelography can sometimes reveal deformity of the anterior wall of the spinal canal. Contrast discography may be useful only in examining the lower thoracic discs.

The clinical course of damage to the thoracic intervertebral discs can occur in two main variants. The first variant is characterized by damage to one intervertebral disc, clinically manifested by pain syndrome with or without compression of the spinal cord elements.

In the second variant, there is damage to several discs, usually manifested by pain syndrome, functional failure of the spine, the presence or absence of symptoms from the spinal cord or its elements.

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Treatment of thoracic intervertebral disc injuries

Conservative treatment of thoracic intervertebral disc injuries

Conservative treatment of thoracic intervertebral disc injuries is similar to the described conservative treatment of lumbar intervertebral disc injuries. As a rule, all fresh injuries of thoracic intervertebral discs are treated conservatively, primarily because they are most often not diagnosed and occur 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 raised much later, when, under the influence of various conservative treatment methods, no cure occurs over a long period of time.

Surgical treatment of thoracic intervertebral disc injuries

Indications for surgical treatment: pain syndrome; single injury to the thoracic intervertebral disc, accompanied by symptoms of spinal cord compression; single injury to the thoracic intervertebral disc without symptoms of spinal cord compression or its elements, but with symptoms of severe functional failure of the spine; multiple injuries to the thoracic intervertebral discs with pain syndrome and functional failure of the spine in young people.

The objective of the surgical intervention is to eliminate the phenomena of compression of the spinal cord or its elements, relieve the victim of pain and stabilize the spine.

Depending on the presence of damage to one thoracic intervertebral disc or several discs, the technical task is solved differently. In the first case, the intervention is performed as a total discectomy and corporodesis, in the second - as a multiple discectomy and anterior spondylodesis. In practice, we have to deal with cases when it is possible to localize the damaged intervertebral disc only approximately. In such cases, we use multiple discectomy in the area of the suspected disc damage.

The surgical intervention is performed under endotracheal anesthesia.

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

The patient's position is similar to that given to the patient during transpleural access.

Technique of surgical intervention for single thoracic disc injury

The affected disc is exposed by a right-sided transpleural approach corresponding to the level of the lesion. The features and details of the technique for exposing the anterior sections of the thoracic vertebrae are described above. This disc is easily identified by a decrease in its height. In doubtful cases, control radiography with marking should be used. Using a thin and sharp chisel, a total resection of the affected disc is performed together with the endplates of the adjacent vertebral bodies. The posterior sections of the intervertebral disc are removed with a bone spoon. A spongy autograft taken from the crest of the iliac wing is inserted into the intervertebral defect. Since the height of the intervertebral defect is usually insignificant in the thoracic region, it is necessary to additionally remove part of the contacting surfaces of the adjacent vertebral bodies 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 equal to 1/3 of the width of the vertebral body, the height is 1-1.5 cm. The size and shape of the autotransplant correspond to the size and shape of this groove. The anterior longitudinal ligament is sutured. The chest wall wound is sutured layer by layer. Drainage is left in the pleural cavity. The postoperative period is no different from the postoperative care of patients with interventions on the bodies of the thoracic vertebrae due to damage to the vertebral bodies. After 3-4 months, a plaster corset is applied for a period of 3-6 months. By this time, bone fusion of the blocked vertebrae usually occurs.

Technique of surgical intervention for multiple damage to thoracic discs

The right-sided transpleural approach corresponding to the level of damage is used to expose the anterior spine to the required extent. The anterior longitudinal ligament is dissected in the form of a valve and folded to the left on the left base. The level of damage and the level of required stabilization of the spine are determined. This level is usually established by narrowed discs, a decrease in the height of the ventral sections of the vertebral bodies, and the presence of bony coracoid growths. If there are difficulties in determining the level of stabilization, radiography with marking should be used. A groove up to 2-2.5 cm wide and 1.5-2 cm deep is cut out along the anterior surface of the vertebral bodies through the corresponding bodies and intervertebral discs at the entire level subject to osteoplastic fixation using a chisel. A mandatory condition is that the groove ends in the area of the vertebral bodies located above and below the outermost damaged discs. The remains of all exposed discs are removed through the formed groove with a bone spoon. A bone-spongy autograft taken from the upper metaphysis of the tibia is placed in the formed groove, the length, width and thickness of which correspond to the dimensions of the groove. Due to the fact that the thoracic spine is usually in a kyphosis position, the depth of the groove in its end sections should be somewhat greater than in its middle section. Then the transplant will be evenly immersed in the groove and will be evenly adjacent to its walls along its entire length. A flap of the anterior longitudinal ligament is placed and sutured over the groove. The chest wall wound is sutured layer by layer.

The postoperative period is carried out in the same way as for interventions for a single thoracic disc injury.