What is thoracic spondylosis?

Thoracic Spondylosis: Definition and Management

Thoracic spondylosis is a degenerative condition affecting the thoracic spine (T1-T12) characterized by facet joint hypertrophy, disc degeneration, and ligamentum flavum ossification, which can lead to back pain and in severe cases, neurological symptoms including myelopathy and radiculopathy.

Pathophysiology and Prevalence

Thoracic spondylosis is less common than cervical or lumbar spondylosis due to:

• Additional weight-bearing support from ribs
• Limited mobility in the thoracic spine
• Smaller disc size compared to cervical/lumbar regions 1

The condition most commonly affects the lower thoracic spine (T7-T12), with studies showing a predilection for the T10-T12 levels 2, 3.

Clinical Presentation

Thoracic spondylosis may present with:

• Thoracic back pain (mid-back pain)
• Radiculopathy (nerve root compression symptoms)
• Myelopathy in advanced cases 4

Common Symptoms

1. Local pain: Thoracic midback pain (76% of symptomatic cases) 1
2. Neurological symptoms (when compression occurs):
   • Motor/sensory deficits (61%)
   • Spasticity/hyperreflexia (58%)
   • Positive Babinski sign (55%)
   • Bladder dysfunction (24%) 1

Diagnostic Approach

Imaging is not typically indicated for acute thoracic back pain without neurological symptoms or red flags 4. However, imaging should be considered in the following scenarios:

When to Image

• Pain persisting despite 6 weeks of conservative management
• Development of neurological symptoms
• Significant functional decline
• Red flags (age >65, history of cancer, unexplained weight loss, etc.)
• History of osteoporosis or chronic steroid use 1, 4

Recommended Imaging

1. Initial imaging: Plain radiographs of the thoracic spine may identify osseous abnormalities 1
2. Advanced imaging:
   • MRI thoracic spine without contrast: First-line for evaluating myelopathy or radiculopathy 1
   • CT thoracic spine: Better for assessing bony details when planning surgical intervention 1

Management

Conservative Management

1. Pharmacological:

   • NSAIDs/COXIBs at maximum approved dosage for 2-4 weeks
   • Consider NSAID rotation if insufficient response
   • Short courses of oral prednisolone as bridging therapy in severe cases 4

2. Physical Therapy:

   • Active physical therapy and supervised exercise (strongly recommended over passive therapy)
   • External bracing (thoracolumbosacral orthosis) for temporary immobilization during acute pain episodes 4

Surgical Management

Surgery should be considered only after failure of conservative management, except in cases with:

• Signs of myelopathy
• Progressive neurological deficits
• Evidence of spinal cord compression on imaging 4

Surgical options include:

• Posterior decompression with fixation/fusion for thoracic spondylolisthesis secondary to disc degeneration 5
• Decompressive laminectomy for localized stenosis 6

Prognosis

• Good prognosis for at least partial recovery with appropriate treatment, even in those with long-standing disease 3
• Surgical decompression for localized stenosis yields good results
• Prognosis is more guarded for those with diffuse or segmental stenosis 6

Common Pitfalls

1. Misdiagnosis: Often confused with lumbar spondylosis due to overlapping symptoms 5
2. Delayed diagnosis: Due to its rarity and complex symptomatology 6
3. Premature imaging: Avoid imaging for acute thoracic back pain without red flags or neurological symptoms 4
4. Surgical complications: Ossified ligamenta flava may adhere tightly to the dura mater, increasing surgical difficulty 2

Remember that morphologic imaging changes of osteoarthritis do not always correlate well with pain, so imaging should be used judiciously as part of a comprehensive management approach 4.