Thoracic Cyst

The thoracic area is that portion of the spine between the neck and the low back. A cyst is a fluid filled sac; therefore, a thoracic cyst is a fluid filled sac that occurs in the thoracic spine.

What Are Thoracic Spine Cysts?

Cysts are abnormal, closed sacs that contain fluid, gas or semi-fluid material. They can develop in various parts of the body. They can vary in size from very small to large and can be located within organs, tissues or bones. 

Cysts can be either benign (non-cancerous) or malignant (cancerous). Most cysts are benign. They occur due to a number of different reasons that include obstruction, infection, chronic inflammation, instability or cellular abnormalities. 

So, thoracic spine cysts are abnormal, closed sacs that occur in the spine below the neck and above the low back.

Types Of Spinal Cysts

In the following video, I go over the 4 types of spinal cysts and how we treat them at the Centeno-Schultz Clinic:

There are four principal types of thoracic cysts. They include:

• Synovial cyst: A synovial cyst, also known as a ganglion cyst, is a benign fluid-filled sac that typically forms on or near joints, tendons or ligaments. The synovium is specialized connective tissue that lines the inner surface of certain joints and tendons. It produces synovial fluid, which is a thick, lubricating substance that fills the joint. It reduces the friction between bones within a joint, allowing for smooth, painless movement. 

• Vertebral body cyst: Vertebral bodies are the boney building blocks in the spine. Vertebral bodies stack one upon the other. The thoracic spine has 12 vertebral bodies that are numbered in ascending order from T1-T12. So, a vertebral body cyst is an abnormal, fluid filled sac that occurs within a bony vertebral body. Vertebral body cysts are not very common.¹

• Perineural cyst: Peri means around, and neural refers to nerve tissue. So, a perineural cyst is a cyst that forms around or within a nerve. Perineural cysts, also known as Tarlov cysts, are cebrospinal fluid-filled cysts that develop at the intersection of a dorsal root ganglion and the posterior nerved root. They are typically asymptomatic (show no symptoms) and an incidental finding during routine spine imaging.² 

• Spinal cord cyst: A cyst can also form within the spinal cord and are often referred to as syrinx or syringomyelia. A syringomyelia is a rare neurologic disorder characterized by slowly developing a fluid filled area that extends within and down the spinal cord. Common symptoms include pain, weakness and stiffness. 
  
  Syringomyelia has a prevalence of 3.3 to 8.5/100,000 people.³ It is typically seen in conjunction with type 1 Chiari malformations (a condition where the brain tissue extends into the spinal canal).⁴

Thoracic Spinal Cyst Symptoms

The symptoms associated with a thoracic spine cyst can vary significantly, depending upon the location, the size of the thoracic cyst and whether it is encroaching upon adjacent structures. The most common thoracic spinal cyst symptoms include:

Pinched Nerves In The Back

Thoracic cysts can irritate or compress nerves in the back, leading to pain and restriction in range of motion. The pain can be mild, moderate or severe. It can be unilateral (affecting only one side) or bilateral (affecting both sides). The pain can be localized in the thoracic spine or, depending upon the location and the severity of the thoracic cyst, may radiate across the chest wall or abdomen.

Left Arm Numbness

Left arm numbness can occur as a result of two different types of thoracic cysts. 

A cyst in the thoracic spinal cord (known as a syringomyelia), can cause arm numbness. The most common sensory symptom of a syringomyelia is numbness and alteration in sensation.⁷ A perineural cyst can also compress an exiting nerve root, leading to arm numbness.⁸

Pain When Sitting

Syringomyelia (a cyst in the spinal cord) or a synovial cyst (a cyst around the perineural nerve) can cause pain when sitting. 

Pain When Standing

A perineural cyst, syringomyelia or synovial cyst can cause pain upon standing, due to irritation of the exiting thoracic nerves of the thoracic spinal cord.

Leg Giving Out

A thoracic cyst can lead to a number of debilitating symptoms, including a person’s leg giving out. A thoracic perineural cyst can irritate or compress an exiting nerve root, leading to weakness in the upper and lower extremities. This weakness can show up as a patient’s leg giving out.

A thoracic synovial cyst can also lead to lower extremity weakening and the leg giving out. The synovial cyst can irritate or compress an exiting nerve, leading to weakness.

Finally, a spinal cord cyst, a syringomyelia, can compress or injure the motor tracts within the spinal cord, leading to weakness in the lower extremities. 

Arm Throbbing

In many patients, irritated neck nerves don’t present as a symptom in the neck. In fact, sometimes the only symptoms of irritated nerves in the neck occur in the arm muscles, as either tightness, throbbing, or both. While the arm throbbing might be frustrating as it’s happening, you might not think a whole lot about it, especially if it only happens on occasion. However, ignoring it is not a good idea since it is often a warning signal of a bigger problem in the neck. These body connections occur all the way back to when we were a fetus, like the neck, shoulder, and arm.

Read More About Arm Throbbing

Back Pain in Ribs

Experiencing thoracic spine and rib pain? Learn more about what could be causing this and the treatment options that can provide lasting relief. Back pain in the ribs can be a common and often debilitating condition, causing discomfort and limiting mobility for many individuals. The pain can range from mild to severe and may be caused by various underlying conditions. Understanding the many causes of rib and back pain is important and can assist in securing an accurate diagnosis. Treatment options vary depending on the underlying cause and severity of symptoms.

Read More About Back Pain in Ribs

Left Arm Numbness

Treatment depends upon the underlying cause of the arm numbness. Left-arm numbness is a warning sign that requires attention. As noted above unexplained numbness requires immediate attention. At the Centeno-Schultz Clinic, we are experts in the treatment of left-arm numbness due to cervical nerve irritation, cervical stenosis, thoracic outlet syndrome, and peripheral nerve injuries. When appropriate first-line treatment should involve conservative care including physical therapy and stretching. Steroid injections should be avoided as they are toxic to orthopedic tissue and can accelerate damage. Surgery for Cervical Stenosis and Thoracic…

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Leg Gives Out

Have you ever been walking and your leg gives out? It can be both surprising and alarming What would cause your leg to give out? Can sciatica cause your leg to give out? How do you treat weak legs? Let’s dig in.Weakness in the leg can arise from three principal sources: nerve problems, muscle weakness, and SI joint dysfunction. Weakness in the legs may indicate a significant nerve problem. In many cases, it may be the first indication of a nerve problem. There are three common causes of nerve injury: low back disorders, nerve compression as it descends down into the hip, thigh, and shin and medical conditions such as diabetes…

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Referred Pain From The Thoracic Spine

Pain is the body’s way of signaling distress or injury. But what if your body manifests pain in a certain area of your body and yet the actual source of the discomfort is a completely different part of your body? In this article, we will explore the intricacies of referred pain, specifically referred pain from the thoracic spine. We’ll explore what this typically feels like, what conditions commonly cause referred pain, and the treatment options available to treat the root cause of this symptom.

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Thoracic Facet Joint Pain

Symptoms of a thoracic facet joint injury will vary depending upon severity of the injury and which facet joint is injured. The joints have established pain referral patterns (2). Drefus et al demonstrated that pain from a given facet joint does not occur in the immediate area of the joint in 75% of cases. Rather, it refers to an area away from the joint. For example, pain from injury of the T3/4 facet is felt along the inside border of the scapula. Unfortunately, there is significant overlap between the thoracic referral patterns which can complicate identifying the exact facet joint…

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Thoracic Spine Tightness

Thoracic spine tightness can be caused by a number of different conditions. Many providers and medical practices focus on treating symptoms, with the aim of reducing them. Therefore, they provide prescriptions for different medications and referral to physical therapy with the hope that this will reduce or eliminate symptoms. At the Centeno-Schultz Clinic, we take a different approach. We believe that the first step is an accurate diagnosis. By identifying the accurate underlying issue, patients can receive the appropriate therapy and get the best clinical results. The process starts with a board-certified, fellowship-trained physician taking a detailed history that includes the onset of symptoms, presence or absence of trauma, aggravating factors, alleviating factors, and treatment to date.

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Common Causes Of Thoracic Spine Cysts

The exact cause of thoracic spine cysts is unknown. There are many theories that speculate on the possible causes, including:

Natural Degeneration Of The Spine

General wear and tear of the spine has been identified as a possible cause of thoracic spine cysts. Specifically, synovial cysts are thought to be caused by the degeneration of the thoracic facet capsule (one of the structures that keep the spine stable during movement of the body).⁵

Instability Due To Repetitive Motion

Instability in the thoracic spine can create havoc as it places abnormal forces on the thoracic facets, discs, tendons, ligaments and nerves. These forces can lead to irritation of the layers covering the spinal cord and thoracic nerves, potentially leading to the formation of perineural cysts.⁶

Rheumatoid Arthritis

Rheumatoid arthritis is an autoimmune condition that affects the joints and spine, causing inflammation, pain, and degeneration. It can cause significant inflammation and degeneration in the spine, potentially leading to the formation of thoracic spine cysts.

Degenerative Disk Diseases

Degenerative disc disease refers to the gradual breakdown of the soft, gelatinous shock absorber that is sandwiched between the boney building blocks in the spine. This degeneration can lead to increased and abnormal forces on the thoracic facets and nerves. Over time, this increased stress can potentially lead to degeneration of the facet capsule, leading to synovial cyst formation. In a similar fashion, degenerative disc disease can cause spinal cord and spinal nerve irritation or compression, potentially leading to perineural or spinal cord cyst formation. 

Diagnosing Cysts On The Thoracic Spine

Securing an accurate diagnosis is essential for the best clinical outcomes. Without an accurate diagnosis, an appropriate treatment plan cannot be developed, and time, money and hope may be wasted.

At the Centeno-Schultz Clinic, an accurate diagnosis is paramount. The process involves a detailed medical and surgical history, and obtaining information about the onset of pain, alleviating and aggravating factors and treatment to date.

A thorough physical examination is performed with evaluation of range of motion and assessment of neurologic function. Radiographic studies include X-rays and MRI. These studies are reviewed in detail with the patient. When appropriate, an in-office ultrasound is performed to identify areas of injury and instability.

Common Treatments For Thoracic Spine Cysts

Thoracic cysts occur in the facet joints, vertebral bodies, nerve sheaths, and spinal cord. Location, size of cyst and irritation or compression of adjacent tissue will dictate treatment options. When appropriate, conservative care should always be the first line of treatment.

Medications

The pain associated with a thoracic lesion is dependent on many factors, including the location of the lesion, its size and whether it is compressing or injuring the adjacent tissue. Common medications include:

• NSAIDs: NSAIDs (non-steroidal anti-inflammatory drugs) are powerful anti-inflammatory agents. Common examples include ibuprofen, naproxen, voltaren and celebrex. They are available in both tablets and topical creams. They have significant side effects, which have been previously discussed and should be avoided. 
• Oral Narcotics: Narcotics are powerful medications designed to reduce pain and increase function. They have significant side effects, which include dependence, and therefore should be avoided. Furthermore, they do NOT address the underlying lesion. Rather, they simply mask the pain.
• Corticosteroids: Corticosteroids are a type of medication that reduce inflammation and immune responses. Common names include prednisone, hydrocortisone, dexamethasone and “Dosepak”. They work by inhibiting transcription factors that control the synthesis of pro-inflammatory mediators such as macrophages, eosinophils, lymphocytes, mast cells, and dendritic cells. 
  
  They also inhibit phospholipase A2, which produces numerous inflammatory mediators. They are prescribed for arthritis to reduce local inflammation and prevent further bone destruction. Corticosteroids can be taken orally or injected directly into the joint. 
  
  However, as corticosteroids reduce the density of the bone, when taken for extended periods, they are not a permanent treatment option. There are other significant adverse side effects, which have been previously discussed.

Steroid Injections

When conservative care and medications fail, some patients are referred to a pain clinic for steroid injections. As previously discussed, steroids are powerful anti-inflammatory agents that have a number of adverse side effects. The steroids are injected into the area of injury.

For thoracic cysts located in the vertebral bone and the spinal cord, steroid injections are not an option, as steroid injection into the spinal cord could lead to severe spinal cord injury and paralysis.

Minimally Invasive Spinal Surgery

Thoracic spine surgery is reserved for those patients for whom conservative care, medications and steroid injections have failed. The specific type of surgery will depend upon a number of factors that include location of the cyst, its size and whether adjacent tissue is irritated or injured.

Common thoracic surgeries include:

• Laminectomy: removal of the lamina and opening up a narrowed/stenotic central canal.
• Facetectomy: removal of portion or the entire facet to decompress and restore function in exiting nerves.
• Discectomy: removal or a portion of the injured thoracic disc.
• Artificial disc replacement: removal of the injured disc, which is then replaced with an artificial disc.
• Fusion: removal of the injured disc, which is then replaced by spacers and or bone graft and stabilized by screws and rods.

Can Regenerative Treatments Help?

Degeneration and spinal instability can lead to thoracic cyst formation. When unresponsive to conservative care, regenerative treatment options can be viable, allowing patients to avoid dependency on medication or the significant risks and potentially life changing results of thoracic spine surgery. 

Rather than amputate the diseased or compromised tissue, PRP and bone marrow concentrate can accelerate healing.

Physical Therapy

Physical therapy can play a significant role in the treatment of cysts in the thoracic spine by addressing pain, improving mobility, and restoring function.

Platelet-Rich Plasma (PRP) Therapy

Platelet rich plasma is a regenerative treatment option where blood platelets are concentrated and injected into areas of injury or degeneration. Blood is drawn from the patient’s arm and then processed, whereby the red blood cells and plasma are discarded. Platelets are rich in a large number of growth factors that can increase blood flow and decrease inflammation.

At the Centeno-Schultz Clinic in 2017, we demonstrated that PRP is highly effective in the treatment of sciatica type pain arising from a low back disc injury.⁹ PRP is an attractive alternative to steroids injections, as it has no known systemic effects and can actually facilitate healing by increasing blood flow.

Many of the patients with perineural cysts who have undergone injections with PRP have reported a reduction in pain and increase in function.

Deep Dive

Facet Cyst Treatment

When a cyst develops on a facet joint in the spinal column, it can be painful and even debilitating for many patients. However, some patients may not even know they have a facet cyst as they may be asymptomatic. If you’re in the former category, and your cyst has been wreaking havoc in your back, your doctor may throw out the S word—”surgery.” Facet cyst surgery is certainly the most invasive option, but is it the only option? Let’s learn more about the facet joint and facet cysts.

Read More About Facet Cyst Treatment

Laminectomy

Lumbar Spinal Stenosis (LSS) is one of the most diagnosed spinal disorders of patients over 45 years old. At least 200,000 adults in the United States have LSS symptoms that require treatment. The Framingham Study reported a prevalence of absolute Lumbar Stenosis of 47.2% for patients aged 60–69 years, with this number increasing with age. Lumbar Stenosis refers to the narrowing or crowding of the spinal nerves as the travel down the spinal canal or as they exit the spinal canal via foramen. Narrowing or crowding of the nerves can be caused by multiple things in the spinal canal: 1. Disc bulge / herniation push…

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PRP Injections

PRP is short for platelet-rich plasma, and it is autologous blood with concentrations of platelets above baseline values. The potential benefit of platelet-rich plasma has received considerable interest due to the appeal of a simple, safe, and minimally invasive method of applying growth factors. PRP treatments are a form of regenerative medicine that utilizes the blood healing factors to help the body repair itself by means of injecting PRP into the damaged tissue. In regenerative orthopedics, it is typically used for the treatment of muscle strains, tears, ligament and tendon tears, minor arthritis, and joint instability. There have been more than 30 randomized controlled trials of PRP…

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Thoracic Spine Surgery

Thoracic spine surgery is a major surgery aimed at treating injuries in the thoracic spine. Because of the complex anatomy and close proximity to the heart and lungs, there are significant surgical risks and complications. Surgery on the thoracic spine can take hours and may require deflating the lung in order to gain access to the thoracic injury. Recovery can be lengthy depending upon the specific thoracic spine surgery performed. There are several different types of thoracic spine surgery.  The specific thoracic spine performed depends upon the underlying thoracic injury and a symptoms of the patient.  For example, a thoracic disc herniation…

Read More About Thoracic Spine Surgery

Get Proper Diagnosis And Treatment For Spinal Cyst for Any Case

Cysts are abnormal, closed sacs that contain fluid, gas or semi-fluid material. They can occur throughout the body, including in the thoracic spine. 

There are four major types of thoracic spine cysts: synovial, vertebral body, perineural and spinal cord. Symptoms and treatment options of a thoracic cyst vary, depending upon the location of the cyst, its size and whether there is any irritation or compression of adjacent tissue.

At the Centeno-Schultz Clinic, we understand that an accurate diagnosis is critical. It starts with a thorough review of medical history, physical examination and review of radiographic studies. 

Spinal instability is often present, and the integrity of the thoracic muscle and ligaments needs to be accurately assessed. This can be accomplished by a thorough physical examination and in- office ultrasound. This is completed at the time of new patient evaluations.

PRP and bone marrow concentrate, which contains stem cells, are treatment options of thoracic spine injuries, including perineural cysts.

At the Centeno-Schultz Clinic, we are experts in the evaluation and management of thoracic spine injuries. If you or a loved one suffer from thoracic pain that has not responded to conservative or medical management, please consider a consultation. A board certified, fellowship trained physician will review your candidacy for regenerative treatment options.

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Thoracic Spine Physician and Expert

John Schultz, MD

John R. Schultz M.D. is a national expert and specialist in Interventional Orthopedics and the clinical use of bone marrow concentrate and PRP for orthopedic injuries. He is board certified in Anesthesiology and Pain Medicine and underwent fellowship training. Dr. Schultz has extensive experience with same day as well as culture expanded bone marrow concentrate and sees patients at the CSC Broomfield, Colorado Clinic, as well the Regenexx Clinic in Grand Cayman. Dr. Schultz emphasis is on the evaluation and treatment of thoracic and cervical disc, facet, nerve, and ligament injuries including the non-surgical treatment of Craniocervical instability (CCI).

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