Background & Etiology
The intervertebral disc is a fibrocartilaginous structure found between the bodies of the vertebra. There is a disc between each pair of vertebra in the spine except for the first and second cervical level (atlas and axis).
The disc is similar to a jelly donut. It has a series of outer fibrous rings (annulus fibrosis) surrounding a gelatinous center (nucleus pulposus). The outer annular rings are thinnest posterior and lateral. Most disc herniations occur here due to the weakness of the disc wall. The disc functions as a cushion, allows for movement, and serves as a cartilaginous joint between adjacent vertebrae.
Inflammation, damage or degeneration of a disc can cause a range of symptoms that vary based on the severity of the problem. Disc pathology may produce a loss of back motion, back pain, pain that may radiate from the back around the ribs and chest, numbness, tingling, muscle spasm or some combination of these symptoms. The most common area of thoracic disc problems occurs between T8-T12. Thoracic disc degeneration occurs far less than in the lumbar and cervical areas because the thoracic spine is less mobile than these other areas of the spine.
Common conditions of the intervetebral disc include bulging disc, herniated disc, prolapsed disc, degenerative disc disease, anular tear of the disc, ruptured disc and slipped disc.
Degenerative Disc Disease
Degenerative disc disease is not an actual disease but is the term used to describe the progression of changes, gradual wear and tear, and dysfunction associated with symptoms secondary to disc degeneration. Degeneration of the disc is normal with aging but can be accelerated in certain situations as a result of trauma, repetitive strain or injury and musculoskeletal imbalances like scoliosis. Disc degeneration itself is not a problem, but the associated conditions that may develop as it progresses can be symptomatic and debilitating.
Stages of Disc Degeneration
The progression of disc degeneration can be classified in the following phases:
- Tears of the annular rings of the disc with irritation of the facet joints at the corresponding spinal level may occur.
- There is loss of joint mobility, localized back pain, muscle spasm, and loss of movement especially extension or backward motions.
- Loss of disc fluid with dehydration and disc narrowing. The facet joints and capsule may develop laxity resulting in instability.
- A patient will present with pain, sharp catching, giving way, a shift in spinal alignment and loss of motion.
- The body reacts to the instability by laying down bone in the form of osteophytes to stabilize the spine. This increase in bone formation can result in Stenosis.
- Back pain will usually decrease, but remain present in a less severe form. Individuals may develop stenotic-like symptoms.
- Aging is the most common cause of disc degeneration. As the body ages the discs start to lose fluid and dehydrate. The discs start to narrow and lose their height, compromising their ability to absorb shock and stress.
- The outer fibrous annular rings may begin to crack and tear, weakening the disc walls.
- Individuals who smoke, are obese, and are involved in activities that require heavy labor are more likely to develop disc degeneration.
- Sudden fall or trauma to the spine or disc may begin the degenerative process.
- A disc herniation may initiate the stages of disc degeneration.
- Unlike muscles, there is minimal blood supply to the discs, so they lack reparative ability.
Conditions of the intervertebral disc that can develop as a result of disc degeneration include bulging disc, herniated disc, prolapsed disc, degenerative disc disease, annular tear of the disc, ruptured disc and slipped disc.
The symptoms associated with degenerative disc disease of the thoracic spine will depend on the location and structures that are affected. Thoracic disc degeneration can affect the back, shoulder blade, and run along the distribution of the ribs.
- Many patients with DDD (degenerative disc disease) do not exhibit symptoms.
- Chronic thoracic pain with or without radiation to the chest wall or ribs
- Sensory changes such as numbness, tingling, or parasthesia if the nerve is compromised.
- Muscle spasm and changes in posture in the thoracic area.
- Loss of motion with decreased ability to move the trunk when performing motions like turning, backward bending, and side bending.
- Sitting for extended periods of time may produce back and arm pain.
- Difficulty with lifting and over the head activities.
- In later stages spinal Stenosis may develop resulting in lower extremity weakness and loss of coordination. In these cases surgical intervention will be required.
Treatment of thoracic degenerative joint disease or injury will depend on the severity of the condition. When treating acute back problems:
- Rest: avoid the activities that produce the pain (bending, lifting, twisting, turning or bending backwards).
- Medication to reduce inflammation (anti-inflammatory drugs and pain medication).
- Ice in acute cases: apply ice to the thoracic spine to help reduce pain and associated muscle spasm. Apply it right away and then at intervals for about 20 minutes at a time. Do not apply directly to the skin.
- Moist heat may be helpful to reduce pain and improve any feelings of stiffness.
- An exercise regiment designed specifically to address the cause of the symptoms associated with the degenerative disc disease and improve joint mobility, spinal alignment, posture, and range of motion.
- The use of supports may be necessary to reduce stress on the facet joints, muscles and thoracic area of the spine.
- Steroidal medication to reduce inflammation in moderate to severe conditions
- Epidural injections directly to the involved disc may be indicated
- Physical therapy to reduce inflammation, restore joint function, improve motion, and help return full function.
In mild cases rest, ice and medication may be enough to reduce the pain. Many patients will do well with this regiment. Once the pain is reduced, physical therapy is recommended to develop a series of stretching and strengthening exercises to prevent reoccurrence of the injury. Return to activity should be gradual to prevent a flare up of symptoms.
Moderate to Severe
If the problem persists, consulting with your health care provider should be the next step. Your physician will perform a thorough evaluation to determine the possible cause of your symptoms, the structures involved, the severity of the condition, and the best course of treatment.
In addition to performing a thorough examination your physician may order the following tests to make a more concise diagnosis:
- X-ray to determine if there is any joint degeneration, fractures, bony malformations, arthritis, tumors or infection present.
- MRI to determine any soft tissue involvement including visualization of the discs, spinal cord and nerve roots.
- CT scans, which can give a cross section view of the spinal structures.
- EMG which is used to determine nerve involvement or damage.
- Myelogram, which involves the injection of dye into the spinal column followed by an X-ray to visualize the position of, and the pressure being applied to, the discs or spinal cord.
Your physician may recommend several medication options individually or in combination to reduce the pain, inflammation and muscle spasm that may be associated with disc injuries.
- Over the counter medications for mild to moderate pain.
- Narcotics, if over the counter medications are not effective your physician may prescribe stronger pain medication.
- Anti-inflammatory drugs or prescription NSAIDS to reduce inflammation following acute injury.
- Muscle relaxers to reduce acute muscle spasm.
- Nerve pain medication by prescription, designed specifically to reduce pain from nerve damage.
- Injections like facet injections, nerve blocks or an epidural. These may involve the injection of corticosteroids to a specific structure to reduce local inflammation.
Severe or Non-responsive Disc Condition
The majority of thoracic disc herniations can be treated successfully without surgery. In the case of conditions that do not respond to conservative care, surgery may be indicated. If you continue to experience some of the following symptoms:
- Increase in radiating or radicular pain
- Pain or nerve damage that gets worse
- The development of or an increase in weakness
- Increase in numbness or parasthesia
- Loss of bowel and bladder control
The most common disc related surgery is a discectomy in which the disc is removed through an incision. However, there are several surgical interventions that may be indicated in the case of degenerative disc disease. Which procedure will be performed depends on the cause of the symptoms. Some examples include foraminotomy, laminotomy, spinal laminectomy, spinal decompression, and spinal fusion.
Physical Therapists are professionals, educated and trained to administer interventions. As defined by The Guide to Physical Therapist Practice, interventions are the skilled and purposeful use of physical therapy methods and techniques to produce changes consistent with the diagnosis, prognosis and the patient or client’s goals.
Your physical therapist will perform a thorough evaluation to assess and determine the following:
- Spinal Examination where the patient is put through a series of movements and tests to determine the most probable cause of the condition.
- Strength: resisted testing is performed to determine if there is associated weakness or strength imbalances.
- Flexibility: tight muscles can contribute to poor mechanics and weakness, thus creating imbalances and making one more susceptible to disc and back injuries.
- Posture Analysis, ADL’s and technique: discuss and observe the activity that may have started the problem. Examination of dynamic and static postures that may have caused or contributed to your current back problem. A review of your current activities at home and work that may or may not be causing or prolonging your present condition.
Physical therapy for back and disc problems must remain conservative at the onset to avoid aggravating the condition. Emphasis will be on rest, reducing the inflammation and increasing the blood circulation for healing. Once the initial inflammation has been reduced, a program of stretching and strengthening will be initiated to restore flexibility to the joints and muscles involved while improving strength and stability to the spine. Your program design will be based on the structure and cause of your symptoms. A program not tailored to your problem could aggravate your symptoms.
Common Physical Therapy interventions in the treatment of degenerative disc disease include:
- Manual Therapeutic Technique (MTT): hands on care including soft tissue massage, stretching and joint mobilization by a physical therapist to improve alignment, mobility and range of motion of the thoracic spine. Use of mobilization techniques also helps to modulate pain.
- Therapeutic Exercises (TE) including stretching and strengthening exercises to regain range of motion and strengthen muscles of the back and abdominals to support, stabilize and decrease the stresses place on the disc and back.
- Neuromuscular Re-education (NMR) to improve posture, restore stability, retrain the patient in proper sleeping, sitting and body mechanics to protect the injured disc and spine.
- Modalities including the use of ultrasound, electrical stimulation, ice, cold laser, traction and others to decrease pain and inflammation of spinal structures.
- Home programs including strengthening, stretching and stabilization exercises and instructions to help the person perform daily tasks and advance to the next functional level.
Most degenerative disc problems improve without surgery and return to normal function. The thoracic spine has a much lower incidence of degenerative disc disease. Duration of treatment can range from 4 to 12 weeks depending on the severity of the symptoms. Patients need to continue with a regiment of stretching, strengthening and stabilization exercises. Use of proper mechanics, body mechanics and awareness of the do’s and don’ts for a healthy back is necessary for a good long-term prognosis. The attitude of, “once you have a back problem, you have a back problem” goes a long way to preventing further injury.