What is the diagnosis and treatment for thoracic spondylosis (degenerative disc disease) of the thoracic spine?

From the Guidelines

Thoracic spondylosis, a degenerative condition affecting the middle portion of the spine, should be initially managed with conservative measures, including over-the-counter pain medications and physical therapy, with imaging studies considered only after 6 weeks of persistent pain or in the presence of red flags, as recommended by the American College of Radiology Appropriateness Criteria 1.

Diagnosis and Treatment Approach

The diagnosis of thoracic spondylosis involves a thorough clinical evaluation, including history and physical examination, to identify potential pain generators and rule out other causes of thoracic back pain. According to the American College of Radiology Appropriateness Criteria 1, uncomplicated acute thoracic back pain and/or radiculopathy does not typically warrant imaging. However, imaging may be considered in patients who have persistent pain despite 6 weeks of conservative treatment or in those presenting with red flags, such as a known or suspected history of cancer, infection, immunosuppression, or trauma.

Conservative Management

Conservative management of thoracic spondylosis typically includes:

• Over-the-counter pain medications, such as acetaminophen (500-1000mg every 6 hours, not exceeding 4000mg daily) or NSAIDs like ibuprofen (400-800mg three times daily with food) for pain relief 1.
• Physical therapy focusing on core strengthening, posture correction, and gentle stretching exercises, performed 2-3 times weekly for 6-8 weeks 1.
• Heat therapy (15-20 minutes, 3-4 times daily) and cold packs for acute pain can provide symptomatic relief.
• Lifestyle modifications, including maintaining proper posture, ergonomic workstations, weight management, and avoiding prolonged sitting, are essential components of management.

Imaging and Interventional Procedures

If conservative treatments fail after 6-8 weeks, further evaluation with imaging studies, such as MRI of the thoracic spine, may be warranted to identify potential actionable pain generators 1. In cases with severe or progressive neurological compromise, interventional procedures, such as epidural steroid injections, or surgical intervention may be considered.

Key Considerations

• The American College of Radiology Appropriateness Criteria 1 provide evidence-based guidelines for the management of thoracic back pain, emphasizing the importance of conservative management and selective use of imaging studies.
• The presence of red flags, such as a known or suspected history of cancer, infection, immunosuppression, or trauma, warrants early imaging and potentially more aggressive management 1.
• A multidisciplinary approach, including physical therapy, pain management, and lifestyle modifications, is essential for optimal management of thoracic spondylosis.

From the Research

Diagnosis of Thoracic Spondylosis

• The diagnosis of thoracic spondylosis, also known as degenerative disc disease of the thoracic spine, can be challenging due to its rarity and similarity in symptoms with other conditions such as lumbar spondylosis 2.
• Imaging studies such as thoracolumbar spinal magnetic resonance imaging (MRI), neurophysiologic studies like motor evoked potential (MEP) or somatosensory evoked potential (SSEP), and dynamic thoracolumbar lateral radiography can aid in the diagnosis of thoracic spondylosis 2.
• Clinical presentations such as low back pain, progressive numbness, weakness, and paraparesis, as well as wide-based gait, increased deep tendon reflex (DTR), and urinary difficulty, can be indicative of thoracic spondylosis 2.

Treatment of Thoracic Spondylosis

• Conservative management techniques such as physical therapy, core strengthening activities, hamstrings stretching, and spine range of motion exercises can be effective in relieving pain and restoring function in patients with symptomatic spondylolysis and grade I spondylolisthesis 3.
• The use of thoracolumbar orthosis can help stabilize symptoms and prevent further progression of the disease 2.
• Surgical intervention, including posterior decompression with fixation/fusion procedures, may be necessary in cases where conservative management is ineffective or in patients with severe symptoms such as paralysis 2.
• Epidural interventions, including caudal, interlaminar, and transforaminal epidural injections, can be effective in managing chronic spinal pain, including thoracic disc herniation, with moderate to strong recommendations for long-term effectiveness 4.

Comparison of Treatment Options

• A study comparing the cost and effectiveness of comprehensive medical management for degenerative lumbar spine disease, including lumbar spondylolisthesis, stenosis, and disc herniation, found that medical management did not result in sustained improvement in pain, disability, or quality of life, and was of minimal value given its lack of health utility and effectiveness and its healthcare costs 5.
• In contrast, surgical intervention has been shown to be effective in improving symptoms and quality of life in patients with thoracic spondylosis, although the decision to undergo surgery should be made on a case-by-case basis, taking into account the individual patient's condition and response to conservative management 2.