What is the management approach for an adult patient with degenerative disc space height loss in the thoracic spine, presenting with chronic back pain?

Management of Degenerative Disc Space Height Loss in the Thoracic Spine

For adults with degenerative disc space height loss in the thoracic spine presenting with chronic back pain but without myelopathy, radiculopathy, or red flags, imaging is not indicated and conservative management should be initiated immediately. 1

Initial Assessment and Imaging Decisions

When Imaging is NOT Indicated

• Chronic thoracic back pain without neurologic symptoms does not warrant imaging, as morphologic changes like disc degeneration and facet osteoarthritis do not correlate with pain and are commonly seen in asymptomatic individuals 1
• Thoracic disc abnormalities including herniations, bulges, and annular fissures are frequently present in people without mid-back pain 1
• Extrapolating from lumbar spine evidence, routine imaging provides no clinical benefit in uncomplicated chronic back pain 1

When Imaging IS Indicated

MRI thoracic spine without IV contrast is the initial imaging modality of choice only when:

• Myelopathy is present (motor/sensory deficits, spasticity, hyperreflexia, positive Babinski sign, or bladder dysfunction) 1
• Radiculopathy develops (mechanical nerve root compression symptoms) 1
• Red flags emerge (infection, malignancy, trauma in osteoporotic patients, or progressive neurologic deficits) 1

Conservative Management Protocol

First-Line Treatment

• Physical therapy focusing on core strengthening and flexibility exercises should be the cornerstone of treatment for degenerative disc disease 2
• Patients must remain active, which is more effective than bed rest for chronic back pain 2
• Self-care education materials based on evidence-based guidelines supplement clinical advice efficiently 2

Natural History

• Most patients respond favorably to conservative management, though a significant number may develop chronic pain 3
• The degenerative cascade involves extracellular matrix degradation, loss of disc height, and subsequent neoinnervation that can generate pain 3, 4

When Conservative Management Fails

Progression Criteria

MRI or CT should be obtained only for patients who:

• Have persistent symptoms despite adequate conservative therapy 2
• Are being considered as candidates for invasive interventions (epidural steroid injections or surgery) 2
• Routine imaging without surgical candidacy does not improve outcomes 2

Advanced Treatment Options

Epidural steroid injections may be considered for persistent radicular symptoms despite conservative therapy 2

Surgical intervention is indicated only for:

• Acute thoracic disc herniation with progressive neurologic deficit 5
• Signs or symptoms of thoracic spinal cord myelopathy 5
• Severe, intractable pain unresponsive to all conservative measures 1

Critical Pitfalls to Avoid

Imaging Correlation

• Findings on MRI or CT must be correlated with clinical symptoms before any treatment decisions 2
• The presence of multilevel degenerative changes should not deter from addressing only the symptomatic level if intervention is needed 2

Surgical Considerations

• Posterior laminectomy has been largely abandoned for thoracic disc disease 5
• Thoracic spondylosis most commonly affects T10-T12 levels 6
• Symptomatic thoracic disc herniations requiring surgery are rare, accounting for only 1-2% of all discectomies 1

Discography Limitations

• Discography should never be used as a stand-alone test for treatment decisions 1
• Recent evidence suggests discography may accelerate disc degeneration 7
• If performed, both concordant pain response AND morphological abnormalities must be present before initiating treatment 1

Pain Mechanisms in Thoracic Disc Degeneration

The pain may originate from:

• Mechanical stimulation of nociceptors in the annulus fibrosus from abnormal disc motion 4
• Inflammatory substances (tumor necrosis factor, interleukins) released during degeneration 4
• Ingrowth of nerve fibers into deeper layers of degenerated discs 4
• Secondary effects on facet joints, ligaments, and muscles 4