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Herniated Thoracic Disc

A herniated thoracic disc is especially difficult because there aren’t as many treatments available as there are for disc herniations in other areas of the spine. To understand Thoracic Disc Herniations, though,  we first need to cover thoracic spine anatomy and function.

What is a Thoracic Herniated Disc?

Intervertebral discs (IVD) are the shock absorbers of the spine. IVDs are made up of 2 things

1. Annulus Fibrosus

2. Nucleus Pulposus

I use an analogy of a jelly donut to explain what is going on in the spine during disc herniations, with the annulus fibrosis being the thick dough structure and the jelly part being the nucleus pulposus.

With disc herniation, the annulus fibrosus get small tears throughout the annulus. An annulus is a bunch of concentric fibers, so, as the fibers get damaged and cut, the pressure that is built up within the nucleus pushes the now weakened annulus outward, creating a bulge or herniation.

The disc begins to weaken via mild degeneration/tearing of the annular fibers, allowing the pressure of the nucleus to push outward ànd continues to tear or progress. Eventually the annular fibers prolapse or bulge, and, if that continues, then extrusion or herniation starts to set in. Ultimately, the annular fibers all rupture, creating sequestration where the nucleus is pushed outside the disc. Again, think jelly donut.

Not every disc will end up sequestered and, many times, we find disc herniations throughout the entire spine. Many of these herniations are asymptomatic but can become symptomatic at any time. Asymptomatic Disc herniations are actually a fairly common finding when looking at MRIs of the spine. Multiple research studies back this up as well – systemic review demonstrated:

“Thirty-three articles reporting imaging findings for 3110 asymptomatic individuals met our study inclusion criteria. The prevalence of disk degeneration in asymptomatic individuals increased from 37% of 20-year-old individuals to 96% of 80-year-old individuals. Disk bulge prevalence increased from 30% of those 20 years of age to 84% of those 80 years of age. Disk protrusion prevalence increased from 29% of those 20 years of age to 43% of those 80 years of age. The prevalence of annular fissure increased from 19% of those 20 years of age to 29% of those 80 years of age.” (13)

When disc herniations become symptomatic is when we consider interventional treatment for your spine. Let’s dig into what those symptoms can be.

Symptoms of a Thoracic Herniated Disc

Many times thoracic disc herniations go undiagnosed for years because the pain mimics many different conditions such as heart attacks, gall bladder problems, stomach or other abdominal problems. (9, 10). It might not be diagnosed until you see a specialty physician who takes the time to listen to your history about what makes it worse or better, and, is able to do a good physical exam. Then getting an MRI of the thoracic spine can be confirmatory. Here is a previous patient for whom the pain was so severe that they considered suicide! The symptoms can include:

Mid-Back Pain

Where and what type of pain your get from a thoracic disc herniation depends on which disc is herniated! There are 11 thoracic discs. The annular fibers, when torn, have sensory fibers that can create intense mid-back pain. With these annular tears, the nerves that innervate the disc become inflamed, sending pain anywhere in the mid-back from between the shoulder blades to next to the lower ribs.

“Discogenic pain,” meaning pain originating from the intervertebral disc, is identified when the pain intensifies with activities/positions that place additional pressure on the disc.  The chart below shows disc pressures in different positions. You can see that slouching while sitting creates a 10-fold increase in the discs compared to laying down. Hence most disc pain gets worse with sitting or bent over position! But many times multiple positions can increase the pain, simple activities such as rolling over in bed, leaning over a counter to brush your teeth, and most commonly, I find patients complain mostly about their commute to work, sitting in their car.

Nerve Pain

If the disc is herniated enough, then it will irritate the exiting nerve root, creating pain along where that nerve goes. Since the thoracic spine goes from the neck to the back, these discs can produce many different symptoms. The upper thoracic spine can send pain into the arm via the T1-T2 disc.  Take a look at the dermatomal map below. Red zones are where the pain can go along, many times abdominal pain from a thoracic disc herniation is mistaken for gastrointestinal issues and actual diagnosis is missed for a long time!

Weakness & Motion Difficulties

The ratio of the spinal canal to the spinal cord is far less in the thoracic spine as compared to the lumbar spine where there is much more room for nerves.  Because of this being a naturally narrow area, even a small disc herniation can create compression of both the exiting nerve roots as well as the descending spinal cord. If either of these gets compressed enough, can create motor symptoms in the form of weakness in the muscles they innervate.

This can be a very serious condition! If weakness and muscle loss start, then this is one situation where surgical interventional is likely the best option to decompress the nerve to prevent any permanent nerve damage and stop the declining muscle weakness!

More Symptoms Associated with Disc Herniation of the Thoracic Spine

Big Toe Numbness

Believe it or not, one of those significant issues that can present as numbness stems from the low back. In the lumbar spine, the nerve that exits the spine at the L5 level branches down through the hip, thigh, knee, lower leg, and, yes, all the way into the foot and toes. So a pinched or irritated nerve at that L5 level in the back can create problems, such as pain, numbness, tingling, and so on, anywhere along the nerve branch. So what can irritate the L5 spinal nerve? The list is long, but it includes disc issues, such as herniated…

Read More About Big Toe Numbness

Calf Muscle Twitching

A twitching calf muscle may seem like no big deal, and if it’s just a temporary annoyance that lasts a couple of days and then goes away, it may be. However, it can also be a warning sign of something bigger, especially if it continues. So, today, we’re going to explain a little about the calf and why it’s not a good idea to ignore calf muscle twitching. If there’s one muscle you’re likely familiar with, it’s the calf muscle. If you reach around and grab your calf and flex it, the muscle you are actually feeling just under the surface is called the gastrocnemius muscle.

Read More About Calf Muscle Twitching

Knee Twitching & Spasms

Knee twitching and or spasms are common occurrences that can be caused by a variety of factors. In most cases, it is not a cause for concern and does not require treatment. However, in some instances, knee twitching may be a sign of a more serious condition. Knee twitching is often accompanied by a feeling of pins and needles or tingling in the knee. It may also be accompanied by a burning sensation. The twitching usually occurs intermittently and lasts for a few seconds. There are a number of things that can cause knee twitching. Some of the most common…

Read More About Knee Twitching & Spasms

Nerve Pain in Knee

Nerve pain in the knee can be very irritating and life-altering during normal activities as well as leisurely pursuits. Nerve pain in the knee can radiate from the lumbar spine, the pelvis, or the small nerves in the knee. It also can begin after surgery from surgical nerve irritation from the incision or can be the type of pain related to knee arthritis. At the Centeno-Schultz Clinic, we are experts in spine, pain management, and non-surgical orthopedics. We perform a thorough physical examination and musculoskeletal ultrasound of your knee to identify the root cause of your pain and how to treat it appropriately….

Read More About Nerve Pain in Knee

Tight Hamstrings & Calves

The hamstrings are a group of muscles in the upper leg. They are located on the backside of the upper leg and are comprised of three muscles:  biceps femoris, semitendinosus, and semimembranosus.  The calf muscles are located on the backside of the lower leg and are comprised of two muscles: the gastrocnemius and soleus.  Tight hamstring and calf muscles can be painful, limiting someone mobility.  They also make lower extremity muscles more vulnerable to injuries.  Tight hamstrings and calves can arise from different sources which include: medication, muscle and tendon injury, overuse, muscle imbalance, dehydration, poor posture, low back injury…

Read More About Tight Hamstrings & Calves

Weak in Knees

Weakness in the knee can be a symptom of many different knee conditions. Some of the most common causes of weakness in the knee include ligament tears, meniscus tears, and arthritis. Another important but often overlooked cause of knee weakness is irritation or injury of the nerves in the low back. If you are experiencing any type of weakness in your knee for long durations of time (3 weeks), it is important to see a doctor to determine the cause. Some of the most common symptoms of knee weakness include difficulty standing up from a seated position, difficulty walking, climbing or descending stairs…

Read More About Weak in Knees

Thoracic Spine Anatomy and Function

Your thoracic spine is the section of the spine that connects your neck (cervical spine) to your low back (lumbar spine).  It is made up of bones called vertebrae that are stacked on top of each other with a disc (cushion) sandwiched between the bones.  Your discs act as shock absorbers and allow the spine to be flexible (1). You have one disc between each vertebra in your spine. There are 12 thoracic vertebrae with 11 thoracic discs between each vertebra.

The thoracic spine has 2 major functions: 1, to protect your spinal cord and 2, to anchor your rib cage to your spine (1).  Thoracic discs are made up of 2 types of tissue: 1, the Nucleus Pulposus (NP) and 2, the Annulus Fibrosus (AF) (2). The annulus fibrosus consists of several layers of fibrocartilage made up of both type I and type II collagen. This gives the disc its strength. Nucleus pulposus is the inner core of the vertebral disc. The core is composed of a jelly-like material that consists of mainly water, as well as a loose network of collagen fibers (3). As seen below, you can think of disc anatomy like a jelly doughnut where the dough on the outside is the AF and the jelly in the middle is the NP.

What Causes Thoracic Disc Herniations?

There are many known causes of thoracic disc herniations. Factors that cause disc degeneration include trauma, metabolic abnormalities, genetic predisposition, vascular problems, and infections.

Thoracic spine, when compared to its counterparts (cervical and lumbar spine), has a relatively low incidence of disc herniations. According to Fogwe et al, “Herniation of the intervertebral disc in the thoracic region makes up only 0.5% to 4.5% of all disc ruptures, 0.25-0.75 of all symptomatic disc herniation and 0.15% and 1.8% of all surgically-treated herniations. About 80% of patients usually present with problems in the third or fourth decades of life” (14).

But once found, sometimes it’s hard to say if the herniation was there previously and an event just aggravated or pushed it to the point it could not function and started causing symptoms. That is why the exact cause of disc degeneration is often believed to be multifactorial. Thus, the following outline only covers causes singularly, but you can think of them as interconnected and interdependent.

Discs can be damaged in many ways (4):

Trauma

Trauma is the most common cause of thoracic disc injuries, i.e. in car accidents or contact sports (7).

Genetic Disposition

Ehlers Danlos Syndrome (EDS), a genetic defect that makes weakened collagen fibers in the disc. EDS can make your discs weaker and, thus, more easily injured (5).

Age-related Changes

With time, discs become weaker over time and can become damaged more easily (6).

Poor Posture

Here I refer to scoliosis or increased curve called “kyphosis,” aka slouching. It places increased stress on the disc resulting in repetitive trauma and eventual damage (8) 

What Are the Symptoms of Thoracic Disc Herniations?

While not all thoracic disc herniations are symptomatic, when they are, they can create a number of different symptoms ranging from upper back pain, mid back pain, arm pain, and even groin pain!

Pain can be generated in 2 different ways:

  1. Directly from the disc called “discogenic pain”
  2. Irritation of the surrounding nerve tissue called “radicular pain
Thoracic Discogenic Pain Diagram - how herniated thoracic disc affects nervous system.

How Do You Treat a Thoracic Herniated Disc?

With any orthopedic condition, it’s important to begin with conservative treatment. Things like physical therapy, acupuncture, medications, and other conservative care can be very helpful. The problem comes when all these conservative treatment options fail to resolve your pain. The next option offered would usually be corticosteroid epidurals, but looking at the research, no high levels of studies exist for long-term improvement using steroid epidurals (11). Here is a quick video outlining why corticosteroids actually have negative long-term detrimental side effects.

Should epidural corticosteroids fail to give relief surgery is generally offered as the only other option. While surgery is an option, it should only be used if all else fails. The biggest problem with surgery is the complication rate is as high as 35%! This is not surprising given the high-value real estate near the thoracic spine: lungs, many large blood vessels, spinal cord, rib cage, and other vital structures. Complications from surgery can be life-threatening. These complications include things like, infections, re-herniation of the disc, persistent pain, further degeneration of the disc, and spinal cord or nerve injury. Some complications do not show up until after surgery. Some show up quickly and some may take months to become evident (12).

Surgical Options

Surgical intervention is considered as a last resort for the treatment of symptomatic thoracic disc herniations with patients unresponsive to conservative treatment. It sounds simples, surgery will allow for the removal of the calcified disc decompressing the region and relieving pressure on the nerve or spinal cord.

Despite advances in thoracic disc herniation surgery, there are still about 20% to 30% complications associated with it (15-16). Several factors contribute to these complications.

  1. Symptomatic thoracic disc herniation is rare making it difficult for doctors to gain enough experience to handle it.
  2. The anatomic nature of the thoracic spines makes it difficult to access the herniations. For example, accessing herniations that are located centrally and anteriorly via posterior vertebral column will mean manipulating the thoracic spine that may result in further spinal cord injury and neurological deficits. Accessing centrally located herniations through the anterior transthoracic approach provides an optimal corridor but also involved with high complications and mortalities.
  3. Herniations that are calcified and adherent the dura risk dura tear during surgery leading to CSF leak and intracranial and orthostatic hypotension and headache.

Non-Surgical Traditional Interventional Treatments

Before a thoracic disc herniation surgery is considered, patients must fail conservative treatments that consist of:

  • Physical Therapy
  • Medication management (medications such as NSAIDS, Steroids, Opioid management, neuropathic medications)
  • Interventional pain management injections
    • Facet steroid injections
    • Medial branch blocks
    • Radiofrequency ablation

All these treatments are designed to give short-term relief but do not address the underlying conditions and help mask the symptoms but even worse these treatments may even advance degeneration!  For example, radiofrequency ablation – burns the sensory nerves to the facet joints BUT that nerve also controls the nerve to the multifidi muscles that support and stabilize each segment of the spine. So, while the sensory nerve is burned, you won’t feel the pain from the joint, over time inhibiting the protecting muscles that support the joint means that over time the joint will increase the stress it has on it and further advance arthritis!

Regenexx may have a better option!

Using orthobiologics such as platelet-rich plasma and autologous cellular therapy to treat various spinal conditions is not new to us. We were the first physicians in the world to use advanced cultured expanded MSCs to inject into disc herniations dating back to the early 2000s! Take a deep dive into all the research we continue to publish in the field of ortho-biologics: https://centenoschultz.com/published-research-articles/

Thoracic disc herniations, we see these often but not as often as we see cervical and lumbar disc injuries.  Looking at recent outcome data, we can see, using the most advanced ortho-biologics have an extremely low surgical conversion rate in the cervical and lumbar spine (<3%) to see more on surgical conversions, read more here https://regenexx.com/blog/which-regenexx-procedures-fail-the-most

Evidence-based medicine using biologics based on your type of disc herniation to optimize your results.  When treating various types of disc herniations, we utilize a custom treatment plan based on your specific details to optimize our results and is why our surgical conversion rate is so low.

New data:

We continue to publish more research on our functional spine model approach. Our more recent publication highlights its use in the cervical spine:

Is There a Better Option?

In the end, there are many ways to treat pain from thoracic disc herniations. As highlighted above, surgical approach can be both risky and ineffective. We have pioneered spine treatments with ortho-biologics over the past 15+ years with documented excellent outcomes and surgical avoidance. If you have been dealing with a thoracic disc and failing to get the results you desire, contact us today so we can review all your imaging, do a thorough examination to discuss possible treatment options.

Our Doctors That Assist With Thoracic Herniations

Christopher J. Centeno, MD

Christopher J. Centeno, M.D. is an international expert and specialist in Interventional Orthopedics and the clinical use of bone marrow concentrate in orthopedics. He is board-certified in physical medicine and rehabilitation with a subspecialty of pain medicine through The American Board of Physical Medicine and Rehabilitation. Dr. Centeno is one of the few physicians in the world with extensive experience in the culture expansion of and clinical use of adult bone marrow concentrate to treat orthopedic injuries. His clinic incorporates a variety of revolutionary pain management techniques to bring its broad patient base relief and results. Dr. Centeno treats patients from all over the US who…

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John Schultz, MD

My passion and specialization are in the evaluation and treatment of cervical disc, facet, ligament and nerve pain, including the non-surgical treatment of Craniocervical instability (CCI). I quit a successful career in anesthesia and traditional pain management to pursue and advance the use of PRP and bone marrow concentrate for common orthopedic conditions. I have been a patient with severe pain and know firsthand the limitations of traditional orthopedic surgery. I am a co-founder of the Centeno-Schultz Clinic which was established in 2005. Being active is a central part of my life as I enjoy time skiing, biking, hiking, sailing with my family and 9 grandchildren.

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John Pitts, M.D.

Dr. Pitts is originally from Chicago, IL but is a medical graduate of Vanderbilt School of Medicine in Nashville, TN. After Vanderbilt, he completed a residency in Physical Medicine and Rehabilitation (PM&R) at Emory University in Atlanta, GA. The focus of PM&R is the restoration of function and quality of life. In residency, he gained much experience in musculoskeletal medicine, rehabilitation, spine, and sports medicine along with some regenerative medicine. He also gained significant experience in fluoroscopically guided spinal procedures and peripheral injections. However, Dr. Pitts wanted to broaden his skills and treatment options beyond the current typical standards of care.

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Jason Markle, D.O.

Post-residency, Dr. Markle was selected to the Interventional Orthopedic Fellowship program at the Centeno-Schultz Clinic. During his fellowship, he gained significant experience in the new field of Interventional Orthopedics and regenerative medicine, honing his skills in advanced injection techniques into the spine and joints treating patients with autologous, bone marrow concentrate and platelet solutions. Dr. Markle then accepted a full-time attending physician position at the Centeno-Schultz Clinic, where he both treats patients and trains Interventional Orthopedics fellows. Dr. Markle is an active member of the Interventional Orthopedic Foundation and serves as a course instructor, where he trains physicians from around the world.

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Matthew William Hyzy, D.O.

Doctor Hyzy is Board Certified in Physical Medicine and Rehabilitation (Physiatry) and fellowship-trained in Interventional Orthopedics and Spine. Dr. Hyzy is also clinical faculty at the University of Colorado School of Medicine in the Department of Physical Medicine and Rehabilitation; In addition, Dr. Hyzy is an Adjunct Clinical Assistant Professor at The Rocky Vista University College of Osteopathic Medicine. Dr. Hyzy also maintains an active hospital-based practice at Swedish Medical Center and Sky Ridge Medical Center. He is also recognized and qualified as an expert physician witness for medical-legal cases and Life Care Planning. He is published in the use of autologous solutions including…

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Brandon T. Money, D.O., M.S.

Dr. Money is an Indiana native who now proudly calls Colorado home. He attended medical school at Kansas City University and then returned to Indiana to complete a Physical Medicine and Rehabilitation residency program at Indiana University, where he was trained on non-surgical methods to improve health and function as well as rehabilitative care following trauma, stroke, spinal cord injury, brain injury, etc. Dr. Money has been following the ideology behind Centeno-Schultz Clinic and Regenexx since he was in medical school, as he believed there had to be a better way to care for patients than the status quo. The human body has incredible healing capabilities…

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Mairin Jerome, MD

Mairin Jerome, MD

Dr. Mairin Jerome is a physiatrist with subspecialty fellowship training in Interventional Orthopedics and Regenerative Medicine. This subspecialty serves to fill the gap for patients who are interested in therapeutic options that lie between conservative treatment and surgery. Dr. Jerome uses regenerative medicine techniques, including prolotherapy and orthobiologics, via X-ray or ultrasound guidance to precisely deliver injections to areas of musculoskeletal injury or degeneration. Orthobiologics refers to tissue harvested typically from a person’s own body, such as platelets (platelet-rich plasma, PRP) or bone marrow, for use in treating painful musculoskeletal conditions. The goal is to stimulate the body’s healing mechanisms to improve pain, function, and decrease inflammation.

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More Resources

  • PRP for Herniated Disc, Bulging Disc, and Disc Protrusion

    Dr. Pitts discusses PRP for Herniated Disc, Disc Bulge, and Disc Protrusion Transcript Hello, everybody. This is Dr. John Pitts of the Centeno-Schultz Clinic, where we are the leaders and inventors of much of the field of interventional orthopedics, which is basically treating and diagnosing musculoskeletal, orthopedic-type problems using injections and regenerative agents rather than … Continued

  • New Treatment for Costochondritis – Thoracic Spine Series

    NEW TREATMENT for COSTOCHONDRITIS What is Costochondritis? Your ribs connect with the sternum (breastbone) via cartilage at synovial-lined joint. Costochondritis is rib pain, specifically a chest wall pain caused by inflammation of the rib cartilages or the area where the ribs meet the sternum, known as sternal articulations (1). In a group of 122 patients … Continued

  • Thoracic Radiculopathy – Thoracic Spine Series

    Thoracic Radiculopathy is thoracic spinal nerve irritation caused by mechanical, or chemical, irritation of the spinal nerve. The term radiculopathy refers to the whole complex of symptoms that can be caused by a nerve root pathology. Thoracic spine has 24 nerve roots. 12 on each side. Symptoms typically correlate to the path of that specific … Continued

  • Facet Joint Injection

    The facet joint is a pair of cartilage lined joints at each level of the spine that provides important stability and resists excessive rotation and extension. Dr. Schultz discusses treatment options, risks, and alternatives to traditional steroid injections.

  • Rib Fracture Surgery – Thoracic Spine Series

    Rib Fracture Surgery – Can It Put You at Risk for Additional Fractures? Your Rib Cage Is Important Your rib cage is a vital area that protects the lungs and provides structure for the muscles that allow you to breathe. Rib fractures, which are surprisingly common, often result from some type of blunt force trauma … Continued

  • Why a Back Fusion May Just Lead to More Fusions

    Today we’re seeing more and more orthopedic surgeons fusing multiple back bones at once. Instead of a one-level lumbar fusion, which fuses two bones together, they’re doing two or three levels, which fuses three or four bones together. We probably don’t have to state the obvious here, but the more levels that are permanently joined … Continued

References:

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  2. González Martínez E, García-Cosamalón J, Cosamalón-Gan I, Esteban Blanco M, García-Suarez O, Vega JA. [Biology and mechanobiology of the intervertebral disc]. Neurocirugia (Astur). 2017;28(3):135-40. https://www.ncbi.nlm.nih.gov/pubmed/28130014
  3. Iatridis JC, MacLean JJ, Roughley PJ, Alini M. Effects of mechanical loading on intervertebral disc metabolism in vivo. J Bone Joint Surg Am. 2006;88 Suppl 2:41-6. https://www.ncbi.nlm.nih.gov/pubmed/16595442
  4. Bowles RD, Setton LA. Biomaterials for intervertebral disc regeneration and repair. Biomaterials. 2017;129:54-67. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5627607/
  5. Tinkle B, Castori M, Berglund B, et al. Hypermobile Ehlers-Danlos syndrome (a.k.a. Ehlers-Danlos syndrome Type III and Ehlers-Danlos syndrome hypermobility type): Clinical description and natural history. Am J Med Genet C Semin Med Genet. 2017;175(1):48-69. https://www.ncbi.nlm.nih.gov/pubmed/28145611
  6. Vergroesen PP, Kingma I, Emanuel KS, et al. Mechanics and biology in intervertebral disc degeneration: a vicious circle. Osteoarthr Cartil. 2015;23(7):1057-70. https://www.ncbi.nlm.nih.gov/pubmed/25827971
  7. Ahmet Ö, Orkun K, Onur Y, Mesut Y, Sedat D. Traumatic Sequestrated Thoracic Disc Herniation; A Case Report. Turk Neurosurg. 10.5137/1019-5149.JTN.23504-18.3 https://www.ncbi.nlm.nih.gov/pubmed/30649791
  8. Meir A, McNally DS, Fairbank JC, Jones D, Urban JP. The internal pressure and stress environment of the scoliotic intervertebral disc–a review. Proc Inst Mech Eng H. 2008;222(2):209-19. https://www.ncbi.nlm.nih.gov/pubmed/18441756
  9. Singh V, Manchikanti L, Onyewu O, et al. An update of the appraisal of the accuracy of thoracic discography as a diagnostic test for chronic spinal pain. Pain Physician. 2012;15(6):E757-75.  https://www.ncbi.nlm.nih.gov/pubmed/23159975
  10. O’Connor RC, Andary MT, Russo RB, DeLano M. Thoracic radiculopathy. Phys Med Rehabil Clin N Am. 2002;13(3):623-44, viii. https://www.ncbi.nlm.nih.gov/pubmed/12380552
  11. Benyamin RM, Wang VC, Vallejo R, Singh V, Helm Ii S. A systematic evaluation of thoracic interlaminar epidural injections. Pain Physician. 2012;15(4):E497-514. https://www.ncbi.nlm.nih.gov/pubmed/22828696
  12. McCormick WE, Will SF, Benzel EC. Surgery for thoracic disc disease. Complication avoidance: overview and management. Neurosurg Focus. 2000;9(4):e13. https://www.ncbi.nlm.nih.gov/pubmed/29225115
  13. Brinjikji W, Luetmer PH, Comstock B, et al. Systematic literature review of imaging features of spinal degeneration in asymptomatic populationsAJNR Am J Neuroradiol. 2015;36(4):811-816. doi:10.3174/ajnr.A4173.
  14. Fogwe DT, Petrone B, Mesfin FB. Thoracic Discogenic Syndrome. [Updated 2020 Nov 1]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2021 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK470388/
  15. Ruetten S, Hahn P, Oezdemir S, Baraliakos X, Godolias G, Komp M. Operation of Soft or Calcified Thoracic Disc Herniations in the Full-Endoscopic Uniportal Extraforaminal Technique. Pain Physician. 2018 Jul;21(4):E331-E340. [PubMed]
  16. Kang J, Chang Z, Huang W, Yu X. The posterior approach operation to treat thoracolumbar disc herniation: A minimal 2-year follow-up study. Medicine (Baltimore). 2018 Apr;97(16):e0458. [PMC free article] [PubMed]

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