Radiculopathy is produced by compression or irritation of a nerve root within the spinal column. With regards to “Thoracic Radiculopathy,” the symptoms are generated from a disease process occurring within the thoracic spine. Myelopathy in contrast occurs when the spinal cord itself is affected, rather than an individual spinal nerve root. Although they are different, their incidence is not mutually exclusive and often a patient may present with both conditions.1
Thoracic myelopathy and radiculopathy may occur secondary to degenerative, congenital, infectious, traumatic, vascular, endocrine, neoplastic or iatrogenic causes. The symptoms of thoracic radiculopathy are multiple and overlap with other conditions affecting the thoracic spine and as such delineating between conditions based on initial patient presentation can be difficult. Thoracic radiculopathy secondary to disk herniation is estimated to occur in roughly 1 million people per year.2 Although the incidence is significant, a classic presentation of painful unilateral radiation is not always seen. A significant number of patients with thoracic disk herniation remain asymptomatic, and discovery is often found incidentally.3
In addition to thoracic disk disease, DM has also been associated with the development of thoracic radiculopathy.4 Thought to occur secondary to peripheral neuropathy from persistently poorly controlled diabetes, the etiology is often a downstream diagnosis given the multifactorial pathologies often affecting the patient.5 Both thoracic disk disease and radiculopathy secondary to DM present with non-specific symptoms such as chest wall pain, pain in the epigastric territory, upper extremity pain, amongst other symptoms. Given the similarity between presenting symptoms, a broad differential is necessary when evaluating patients.
Thoracic myelopathy can result from any pathologic process disrupting the spinal cord from T1-T12. Myelopathy has been associated with thoracic disc herniation (TDH), vertebral body compression fracture, disc calcification, posterior longitudinal ligament and/or ligamentum flavum ossification, spinal stenosis, and anterior spinal cord herniation with prolapse through the dura mater. Infection, including osteomyelitis and epidural abscess are potential sources of spinal compression. Neoplasm is also a consideration, as the thoracic spine is the most common location for spinal metastases. Demyelinating processes including multiple sclerosis must also be considered.9, 10, 12
Iatrogenic causes of thoracic myelopathy have also been associated with a variety of spinal interventions, including epidural corticosteroid injections, spinal anesthesia, and neurolysis procedures using alcohol and phenol. These iatrogenic causes can be secondary to particulate steroid microembolism, vascular injury, vasospasm and direct toxicity of medication to neural structures.13 Thoracic myelopathy may result from ligature during lumbar sympathectomy, prolonged clamping during aortic aneurysm surgery, or trans-operative micro embolization of the anterior spinal cord artery. Dissecting aneurysms can interrupt blood supply to the thoracic cord. The thoracic spinal cord is considered a watershed area and therefore ischemia is a greater threat compared with the cervical or lumbar cord.10 Intrathecal catheters can develop granulomas at the tip causing devastating compressive myelopathy. Radiation therapy can cause demyelination, focal necrosis and vasculitic changes of the thoracic spinal cord.9,12
Epidemiology including risk factors and primary prevention
Disc herniation is significantly less common in the thoracic spine compared with the cervical and lumbar spine, representing less than 5% of disc herniations.20 The most common location for disc herniation in the thoracic spine is at T11-T12.12 Although many of the patients who develop herniation do so secondary to an inciting event, hereditary predilection has been suggested to play potentially play a contributing role. That being said, further research is required to elucidate the role that genetics play in thoracic disk disease.45 Scheuermann’s disease, also known as juvenile discogenic disease, is a condition characterized by hyperkyphosis with involvement of the vertebral bodies and the disks themselves. As such, it has been stipulated that patients with Scherumann’s disease may be at increased risk for TDH.46 TDH has an incidence of approximately 1 per one million persons.6 Asymptomatic TDH have an incidence as high as 37%; these may or may not increase in size and usually continue to be asymptomatic, not requiring any active treatment.7 Most patients present in the fourth to sixth decade, but TDH can affect all age groups with a 3:2 male-to-female ratio.20,21,22 In most cases, thoracic myelopathy is felt to be caused by degenerative changes with subsequent stenosis and cord compression. However, thoracic myelopathy caused by spondylosis is less common compared to myelopathy caused by spondylosis in the lumbar and cervical spine.23
Skeletal: The thoracic vertebral canal has a smaller clearance (9.2 mm) between the spinal cord and the osseous wall than the cervical canal (11.3 mm). The cord/canal ratio in the thoracic spine is 40% compared to 25% in the cervical. Therefore, the thoracic spinal cord and nerve roots are at higher risk of injury from space-occupying lesions.10 The thoracic spine is naturally a stable portion of the spine, given its articulation with the ribs. A robust posterior longitudinal ligament is also protective in the thoracic spine against disc herniation.
Vascular: The ventral 2/3 of the thoracic spine receives its blood supply from the anterior spinal artery and the dorsal 1/3 from two posterior spinal arteries. The anterior spinal artery is fed by 4-5 radicular arteries, the largest of which is the artery of Adamkiewicz, which mainly supplies the lumbosacral spinal cord segments and can enter the cord anywhere from T10 to L5.23,24 It is here where particulate, insoluble steroids can occlude the blood supply to the cord. The venous plexus of the thoracic spine can serve as a conduit for neoplastic metastasis or the seeding of infections to the spine. As mentioned above the thoracic cord is considered a watershed area with a tenuous blood supply compared to the cervical and lumbar spinal cord.10
Neurologic: The spinal nerve is formed by the sensory fibers from the dorsal root and the motor fibers of the ventral root, and it exits the spine via the intervertebral foramen. Compression of the spinal nerve can thus present with sensory and/or motor symptoms.
Most symptoms/signs are due to direct compression of the nerve root or spinal cord by a degenerative disc or zygapophyseal joint. The high spinal cord-to-canal ratio and vulnerable blood supply makes the thoracic spinal cord more susceptible to injury from a TDH.12,24
Disease progression including natural history, disease phases or stages, disease trajectory (clinical features and presentation over time)
Thoracic radiculopathy is generally a reversible disease well managed by conservative treatment. Asymptomatic thoracic disc herniation’s usually resolve without intervention and overtreatment must be avoided.22 Retrospective studies suggest that 77% of patients with symptomatic TDH managed non-surgically return to their prior level of activity.26 Some patients with radiculopathy will have progression of disease to include sensory deficits and motor weakness which may or may not be reversible. The potential deficits include loss of sensation in a band of skin on the abdomen or chest, weakness of the intercostal muscles and potentially weakness of the abdominal muscles. Furthermore, direct cord compression is associated with paraplegia and neurogenic bladder in some instances. If the T1 nerve is involved deficits can be seen with intrinsic hand attributes leading to weakness and muscle atrophy as a secondary effect as well.
Thoracic myelopathy symptoms and signs are varied and depend on the magnitude of cord involvement. Complaints range from subtle weakness to paraplegia and incontinence in some instances. In contrast to patients suffering from thoracic radiculopathy, whom can be treated conservatively in many instances, signs of myelopathy such as bowel or bladder incontinence, profound motor weakness or hyperreflexia warrant prompt surgical evaluation.
Specific secondary or associated conditions and complications
There is evidence to support a link between chronic pain and worsening of depression.27 Chronic back pain can result in significant physical and emotional distress and as such the risk for psychological conditions such as depression is significant. Although not singular to patients with thoracic pathology, it has been stipulated that roughly 50% of patients with enduring chronic pain suffer from depression.15 This has significant implications for the medical system and goal directed therapy during patient evaluation.
Chronic herpes zoster radiculitis is a condition which should be included in the differential for thoracic radiculopathy and has significant implications for patient quality of life. The virus, which is a progenitor of varicella and herpes zoster virus, lays dormant in the dorsal root ganglion of the affected nerve. Common clinical features include dermatomal pain, dysesthesias, and pruritus, amongst other features. The condition is associated with paresis in 1-5% of patients.16 These findings suggest a significant burden on the patient as well as the healthcare system.
Essentials of Assessment
Thoracic radiculopathy most commonly presents with a burning or shooting pain which can present as back, scapular, chest or abdominal wall pain depending on the level affected. The most common presenting complaint is “band-like” chest pain, present in 67% of patients.29 The pain of radiculopathy tends to follow a dermatomal distribution and is worsened by coughing or straining. The figure below demonstrates the various dermatomes.
Myelopathy may manifest only by gait abnormalities and increased tendency to fall. It may, however, be associated with orthostatic or autonomic dysreflexia (in lesions over T6), bowel/bladder dysfunction, sexuality issues, sensory impairment (dysesthesia or anesthesia) and/or motor deficits.2,4,17
An asymmetric, band-like, sensory anomaly in the chest or abdominal wall usually along a single dermatome is suggestive of thoracic radiculopathy. Neuropathic pain may be exacerbated by trunk movements.
Spinal cord injury is classified according to the American Spinal Injury Association (ASIA) Impairment Scale which can be found on its web site.17 Gait abnormalities, sensory deficits, weakness, hyperreflexia, increased muscle tone, bowel and bladder incontinence and up-going toes are generally seen in myelopathy, although subtle myelopathy may not provide definitive findings. In complete spinal cord injury, there will be no rectal sensation and increased rectal tone with no volitional sphincter contraction.2, 4
Myelopathy can present in a variety of unique syndromes, although clinically the symptoms may not fit perfectly into these categories. Injury to the artery of Adamkiewicz leads to anterior cord syndrome, which is damage to the corticospinal tract, anterior horn cells and spinothalamic tracts presenting with hyporeflexia, atrophy, variable motor loss and decreased sensation with preservation of proprioception and vibration sense due to sparing of the dorsal columns.17
Central cord syndrome presents with weakness, hyperreflexia and preserved sacral sensation with bowel and bladder function minimally affected. This syndrome generally causes weakness in spinal levels most proximal to the lesion as the neurons exiting the corticospinal tract for the anterior horn lie centrally in the spinal cord.18
Tertiary syphilis (tabes dorsalis) and Vitamin B-12 deficiency can result in a posterior cord syndrome with an insult to the dorsal columns. This syndrome causes deficits in gait and balance due to proprioceptive loss with relative sparing of motor and sensory tracts.9,12,30
Disability caused by thoracic radiculopathy is usually secondary to pain. Activities of daily living (ADL) and simple work-related tasks may be affected, especially if intrinsic hand function is impaired due to lesions at T1.
Thoracic myelopathy results in functional disability relative to the spinal cord level affected. High thoracic cord lesion may affect trunk control and mobilization of pulmonary secretions. The Spinal Cord Independence Measure (SCIM) is used to further document traumatic and non-traumatic, acute and chronic, spinal cord injuries.43 The Walking Index for Spinal Cord Injury (WISCI) measures SCI patients’ ability to walk and need for assistance.43 The American Spinal Industry Association (ASIA) Impairment Scale may further help predict functional outcomes.30
When thoracic discitis is suspected, a complete blood count (CBC), C-reactive protein (CRP) and blood cultures should be performed. Checking for acid-fast bacillus in immunocompromised patients or travelers from areas with endemic tuberculosis may be needed. Urodynamic studies may be warranted for patients with myelopathy to determine whether urologic dysfunction is secondary to a neurogenic etiology.44
In pursuing conservative management of thoracic radiculopathy it is reasonable to start with plain radiographs and to delay magnetic resonance imaging (MRI). If there is concern for myelopathy, imaging should not be delayed. MRI is the study of choice for evaluation of TDH or intrinsic spinal cord lesions. Neoplasms may need further studies to check for other foci of metastasis (e.g., positron emission tomography [PET] or isotope scanning). MRI is noninvasive and has high soft tissue resolution to evaluate the spinal cord, but it is a more expensive test. Gadolinium is useful in delineating neoplasm and scar formation.22,32
Supplemental assessment tools
Electromyography of thoracic radiculopathy is challenging and rarely performed. This is likely secondary to the potential invasive nature of the study coupled with the low sensitivity attributed to the results.19 Furthermore, EMG nerve conduction studies have a low combined sensitivity and specificity and do not reveal the biological etiology of the lesion. As such, the invasive and costly procedure is often avoided in the clinical setting.47 There is also a risk of pneumothorax from the needle electromyography, and there is no reliable nerve conduction study protocol described. Although they have been studied, there are no definitive recommendations for performance of motor-evoked potentials and transcranial magnetic stimulation. The use of monitoring of motor evoked potentials and somatosensory evoked potentials is an incredibly useful intra-operative tool that provides additional data for surgeons and anesthesiologists operating on or near the spinal cord. Real time intraoperative monitoring of SSEP and MEP help surgeons navigate around the spinal cord without causing long term damage.
Early predictions of outcomes
Fifty percent of patients with ASIA-B classification spinal cord injuries [(i.e., incomplete = sensory but no motor function is preserved below the level of injury (including the sacral segments) will become ambulatory.6 The ASIA Lower Extremity Muscle Score (LEMS) results from adding the bilateral lower extremity muscle strength (normal is 50); values above 30 are associated with community ambulation.31 Abnormally high levels of cytokines, especially IL-6, may suggest poor prognosis and recurrence.33
Environmental and vehicular modifications allow access for patients with SCI who use wheelchairs or other assistive devices. Home evaluations by Occupational Therapy can identify possible safety issues and provide recommendations for adaptive equipment.
Social role and social support system
Treatment of thoracic myelopathy should address patients’ skin integrity, pain, bowel and bladder management, mental health, sexual and reproductive issues, DVT, spasticity, heterotopic ossification, osteoporosis and the potential for development of autonomic dysreflexia. The participation of the entire rehabilitation team is instrumental in helping to reintegrate the individual to society. Physical therapy and occupational therapy assist in strength training and range of motion, assess for adaptive equipment, position and splint to decrease spasticity and avoid contractures. Social workers can assist transitioning patients back home and with community reintegration. Vocational rehabilitation therapists help patients maintain a productive life adapting to patients’ new limitations. The rehabilitation team should also actively engage the patient’s family members and social circle in the rehabilitation treatment program.
A thoracic radiculopathy work-up should be oriented towards ruling out progressive disease that can lead to myelopathy. However, myelopathy can present without classic signs or symptoms and should be suspected with mild neurological symptoms, such as mild gait abnormalities.
Rehabilitation Management and Treatments
Available or current treatment guidelines
Rehabilitation treatment of thoracic radiculopathy will depend on the symptoms present. Nonsteroidal anti-inflammatories, a short course of glucocorticoids and/or physical therapy are commonly utilized treatments but lack evidence in terms of outcomes. There is evidence to support transcutaneous electrical nerve stimulation as being a useful modality for pain control, as it is relatively inexpensive and low risk.34 For long standing thoracic neuropathic pain, gabapentin, pregabalin, amitriptyline or other anticonvulsant agents may be considered given their efficacy in other neuropathic pain conditions.35,36 Opioid pain medications may be used in refractory cases but given their significant addictive potential and side effect profile, discretion must be used.
At different disease stages
Treatment depends on the etiology. The natural history of TDH favors non-surgical treatments. Surgery may be considered for progressive myelopathy or unrelenting radiculopathy. Interventional spine procedures including epidural steroid injections and selective nerve root blocks can provide significant pain relief and also have the potential to provide diagnostic information. There is fair evidence supporting the use of thoracic interlaminar steroid injections for relieving radiating pain.37 Newer thoracoscopic microsurgical techniques show less complications with almost 80% of patients reporting good or excellent pain outcomes.38 If chronic pain significantly interferes with daily activities, the recommended treatment consists of a comprehensive integrated interdisciplinary approach. This includes contributions from a chronic pain specialist, physical therapy, family medicine physician, surgical service amongst others as well.
Coordination of care
Spine surgery, infectious disease, oncology, plastic surgery, urology, psychology, psychiatry, support group, physical and occupational therapies may all play a role, depending on the nature of the clinical symptoms, as indicated throughout this article.
Patient & family education
Patient and family teaching is of paramount importance to foster the understanding of myelopathy, its ramifications and treatment options. The rehabilitation teams should develop specific short-, mid- and long-term goals based on the individual’s functional abilities. Bowel and bladder training, safe transfer education and skin precautions can empower the patient and family, and will hopefully limit hospitalization.
Translation into practice: practice “pearls”/performance improvement in practice (PIPs)/changes in clinical practice behaviors and skills
The physical exam can provide clues to the diagnosis, but oftentimes MRI is required to make a definitive diagnosis. If radiculopathy is expected, it is reasonable to delay MRI, thus reducing unnecessary costs while a trial of conservative treatment is tried for 4-6 weeks.
Cutting Edge/ Emerging and Unique Concepts and Practice
Regenerative medicine injections of stem cells or platelet rich plasma may provide relief to patients,39 but these treatments are still considered investigational as safety and efficacy have not been adequately established. For instance, neural stem cell transplantation is currently being investigated in murine embryonic stem cells for the regeneration of disk material in patients suffering from chronic back pain.40 These studies are in their early phase and have primarily been done in-vitro, although some in-vivo work is currently underway. Furthermore, elucidating between different etiologies of back pain and their potential response to such therapy has not yet been established in the research community. Moreover, preliminary studies performed looking at the efficacy of platelet-rich plasma (PRP) epidural injections in the setting of lumbar radiculopathy and degenerative disk disease are underway although more research is necessary to elucidate its effectiveness in thoracic radiculopathy/myelopathy.48
The use of functional electrical stimulation (FES) and other related devices, including FES bikes, are being promoted in aiding gait, mobility and improving cardiovascular status.42
Gaps in the Evidence-Based Knowledge
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- Ishii M, Nishimura Y, Hara M, Eguchi K, Nagashima Y, Awaya T, Ando R, Haimoto S, Wakabayashi T. Thoracic Disc Herniation Manifesting as Abdominal Pain Alone Associated with Thoracic Radiculopathy. NMC Case Rep J. 2020 Sep 15; 7(4):161-165. doi: 10.2176/nmccrj.cr.2019-0247. PMID: 33062562; PMCID: PMC7538457.
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- Schmalstieg WF, Weinshenker BG. Approach to acute or subacute myelopathy. Neurol Clin Prac. 2010; 75(Suppl 1): S2-S8.
- Yashon D. Spinal injury. New York: Appleton-Century-Crofts;1978, 98.
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- Miyazaki, Masashi et al. “Prevalence and distribution of thoracic and lumbar compressive lesions in cervical spondylotic myelopathy.” Asian spine journal vol. 9,2 (2015): 218-24. doi:10.4184/asj.2015.9.2.218Choi HE, Shin MH, Jo GY, Kim JY. Thoracic radiculopathy due to rare causes. Ann Rehabil Med. 2016;40(3):534-539.
- Ghosh R, Holland R, Mammis A. Thoracic radiculopathy following spinal cord stimulator implantation treated with corticosteroids. World Neurosurg. 2017;100:712.e1-712.e4.
- Kim BH, No MY, Han SJ, Park CH, Kim JH. Paraplegia Following Intercostal Nerve Neurolysis with Alcohol and Thoracic Epidural Injection in Lung Cancer Patient. The Korean Journal of Pain. 2015;28(2):148. doi:10.3344/kjp.2015.28.2.148.
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- Acute herpes zoster radiculopathy of the lower extremity with dermatomal rash and lumbar nerve enhancement on mri. Mayo Clinic Proceedings: Innovations, Quality & Outcomes. 2020;4(5):608-610.
- Pearl NA, Dubensky L. Anterior cord syndrome. In: StatPearls. StatPearls Publishing; 2021.
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- Nirkko AC, Rösler KM, Hess CW. Sensitivity and specificity of needle electromyography: a prospective study comparing automated interference pattern analysis with single motor unit potential analysis. Electroencephalogr Clin Neurophysiol. 1995;97(1):1-10.
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- Deitch K, Chudnofsky C, Young M. T2-3 thoracic disc herniation with myelopathy. J Emer Med. 2009;36(2):138-140.
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- Gay CW, Bishop MD, Beres JL. Clinical presentation of a patient with thoracic myelopathy at a chiropractic clinic. Journal of Chiropractic Medicine. 2012;11(2):115-120. doi:10.1016/j.jcm.2011.10.007.
- Akuthota V, Tobey J. Developmental and functional anatomy of the thoracic spine. In: Slipman CW, Derby R, Simeone FA, Mayer TG, eds. Interventional Spine an Algorithmic Approach. USA: Saunders Elsevier; 2008:767-776.
- Hoehmann CL, Hitscherich K, Cuoco JA. The Artery of Adamkiewicz: Vascular Anatomy, Clinical Significance and Surgical Considerations. International Journal of Cardiovascular Research. 2016;05(06). doi:10.4172/2324-8602.1000284.
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- Kaito HFT. Thoracic Disc Herniation Presenting with Predominant Abdominal Pain. Journal of Spine. 2013;02(05). doi:10.4172/2165-7939.1000144.
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Original Version of the Topic
Ameet Nagpal. Thoracic Radiculopathy/Myelopathy. 10/30/2012
Previous Revision(s) of the Topic
Ameet Nagpal, MD, Daniel Johnson, DO. Thoracic Radiculopathy/Myelopathy. 7/31/2017
Ameet Nagpal, MD, MS, MEd
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Kenneth Brooks, MD
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