Thoracic Disc Herniation

Thoracic disc herniations can be classified as soft (acute nucleus pulposus herniation) or hard (calcified/ossified disc herniations that have become calcified over time). Hard, calcified disc herniations are more common in the thoracic spine than elsewhere and present unique surgical challenges.

Contributing factors include:

• Age-related disc degeneration — the most common underlying cause
• Calcification of thoracic discs — thoracic discs are particularly prone to calcification with degeneration, making herniations firmer and more adherent to the dura
• Scheuermann's disease — a condition of accelerated thoracic disc and vertebral degeneration in younger individuals
• Acute trauma — less common; sudden disc herniation following significant injury
• Repetitive mechanical loading — heavy manual work or repetitive spinal loading

Symptoms of thoracic disc herniation vary depending on whether the herniation compresses a nerve root, the spinal cord, or both. The insidious and variable nature of symptoms often leads to delayed diagnosis.

Mid-Back Pain

Mid-back (thoracic) pain is the most common initial symptom. It may be localised to the site of herniation or radiate around the chest wall in a band-like distribution (thoracic radiculopathy — pain following the path of a compressed thoracic nerve root). The pain may be sharp, burning, or aching.

Thoracic Radiculopathy

Compression of a thoracic nerve root produces a characteristic girdle-like pain that wraps around the chest or abdomen. This can mimic cardiac, pulmonary, or abdominal pathology and is frequently misdiagnosed. Numbness or tingling in the same distribution may accompany the pain.

Spinal Cord Compression (Thoracic Myelopathy)

When the herniated disc compresses the thoracic spinal cord, symptoms of myelopathy develop — affecting the legs and, in severe cases, bladder and bowel function. These include:

• Progressive leg weakness and stiffness (spasticity)
• Gait disturbance and difficulty walking
• Numbness or altered sensation below the level of compression
• Bladder dysfunction — urgency, frequency, or retention

Urgent Symptoms — Seek Immediate Assessment

Seek emergency neurosurgical assessment immediately if you develop rapidly progressive leg weakness, acute urinary retention, or incontinence in the context of thoracic spine symptoms. Acute thoracic myelopathy requires urgent surgical decompression.

Diagnosis requires a combination of clinical assessment and targeted imaging. A high index of suspicion is necessary as symptoms can mimic other conditions. At One Brain and Spine, our Melbourne neurosurgeons use a systematic approach to confirm the diagnosis and plan treatment.

Clinical Assessment

Neurological examination will identify features of myelopathy (spinal cord compression) or radiculopathy (nerve root compression) in the thoracic distribution. Upper and lower limb examination is performed to assess for signs of cord dysfunction.

Imaging

• MRI of the thoracic spine — the definitive investigation, demonstrating the disc herniation, degree of spinal cord or nerve root compression, and cord signal change
• CT scan — essential for thoracic disc surgery planning; demonstrates calcification within the disc, which significantly influences surgical approach selection
• CT myelogram — used in selected cases where MRI is insufficient or contraindicated
• SPECT bone scan – used to define any bony inflammation which may be contributing to your pain.  If positive, you may benefit from a fusion in addition to a decompression if surgery is required

Non-Surgical Treatment Options

Thoracic disc herniations causing only mild radicular pain without myelopathy may be managed conservatively initially, with:

• Analgesic and anti-inflammatory medications
• Neuropathic pain agents — such as gabapentin for radicular pain
• Physiotherapy — thoracic mobilisation and postural correction
• Activity modification
• Thoracic epidural or nerve root injections — for radicular pain without myelopathy

When is Surgery Required?

Surgery is required when there is significant spinal cord compression causing myelopathy, when radicular pain is severe and refractory to conservative management, or when neurological deficits are progressing. Thoracic myelopathy is a serious condition that requires prompt surgical intervention — delay risks permanent neurological injury.

Surgical Treatment Options

Surgical decompression of thoracic disc herniation is technically complex due to the proximity of the spinal cord and the thoracic anatomy. The surgical approach must be carefully selected based on the level, laterality, and calcification of the disc herniation. One Brain and Spine's Melbourne neurosurgeons are experienced in the following approaches:

Thoracoscopic (Minimally Invasive) Discectomy

A minimally invasive thoracoscopic approach accesses the thoracic disc through small keyhole incisions in the chest wall, using a camera and specialised instruments. This avoids the morbidity of open thoracotomy and is suitable for selected soft lateral disc herniations.

Lateral Extracavitary / Costotransversectomy Approach

This posterior-lateral approach accesses the disc from the back and side, removing part of the rib head and transverse process to reach the disc without entering the chest cavity. It is suitable for calcified and centrally located herniations.

Transpedicular Approach

A minimally invasive posterior approach through the pedicle of the vertebra, suitable for selected lateral or paracentral herniations.

Endoscopic discectomy

Certain thoracic disc herniations will be suitable for an endoscopic approach allowing the disc to be access through the nerve exit canal (foramen) directly anterior (in front) of the spinal cord.  This requires specialised instruments and expert training but may be successful in decompressing the spinal cord using ultra-keyhole techniques.  Recovery from this approach is quicker however the surgical technique requires expert sub-specialist trainng.  This approach will be offered to well selected patients at One Brain and Spine.

Decompression and Fusion

On occasions the approach to discectomy will lead to spinal instability due to the resection of bony structures vital for spinal stability.  As such fusion using screws and rods may be indicated.  These are placed using the latest navigation and robotics at One Brain and Spine.  

Recovery and Prognosis

Recovery depends on the degree of spinal cord compression prior to surgery and the surgical approach used. Most patients with myelopathy experience stabilisation or improvement of neurological symptoms following decompression. Patients with mild pre-operative deficits tend to recover more completely than those with prolonged, severe compression.