Disorders of the thoracic spine: Non-disc lesions

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Disorders of the thoracic spine

Non-disc lesions

Chapter contents

Introduction

Warning symptoms and signs

Symptoms

Signs

Pathology: see the online content

Introduction

Non-disc lesions of the thoracic spine comprise the following disorders:

• Tumours

• Extradural haematoma

• Spinal cord herniation

• Spinal canal stenosis

• Vertebral fracture

• Chest deformities

• Fracture of a transverse process

• Spinal infections

• Lateral recess stenosis

• Localized lesion of costovertebral and costotransverse joints

• Localized lesion of a facet joint

• Paget’s disease.

Very often, the signs and symptoms of the non-discal lesions of the thoracic spine resemble those of discodural disorders.

Some of the lesions mentioned are serious and even life-threatening. Therefore examiners must be on their guard and should immediately request further investigation whenever there is doubt about the exact diagnosis.

Warning symptoms and signs that warrant the examiner’s attention are listed here and are summarized in Box 28.1.

Warning symptoms and signs

Symptoms

Central pain radiating bilaterally around the thorax and spreading anteriorly towards the epigastrium

Although a posterocentral disc protrusion may provoke this type of pain, a tumour or an extradural haematoma should always be excluded.¹

Signs

The following may draw attention to non-discal lesions.

Gross limitation of both side flexions and rotations

In older patients it is normal for these movements to be diminished in range, although the limitation should not be major. In younger patients gross limitation is never normal; if present, it usually points to a non-mechanical disorder, such as ankylosing spondylitis or a tumour.

Gross limitation of extension

In an ordinary disc lesion it is usually anteflexion or one of the rotations that is most painful and limited. If active extension is severely limited and painful, attention is drawn to the possibility of a fracture of a vertebral body, an infection or a tumour. There is only one type of thoracic disc lesion in which severe limitation of active extension can occur: acute thoracic lumbago. In acute thoracic lumbago, other movements are, of course, also limited and/or painful.

Pain and limitation of side flexion away from the painful side as the only positive finding

This pattern suggests that a lesion is being stretched to such an extent that the pain becomes so severe such that the movement is arrested involuntarily. This may indicate a neoplasm in the lung or abdomen, or a thoracic neurofibroma.

Flexion with a rigid thoracic segment

Absence of movement at the thoracic level indicates a disorder other than a disc lesion. Ankylosing spondylitis is a possibility, as are advanced osteoarthrosis, fracture, tumour or a vertebral infection.

Neurological signs

The presence of one of the following neurological signs should always put examiners on their guard.

• Signs of involvement of multiple nerve roots

• A band-shaped area of numbness related to one or more dermatomes

• All signs of spinal cord involvement 2–4 (see p. 390).

A large space-occupying process, or a large disc protrusion which cannot and may not be manipulated, is very likely and a myelogram or magnetic resonance imaging (MRI) should be ordered immediately.

Muscle spasm

If one of the passive movements is stopped by an involuntary muscular contraction, a serious disorder should be suspected.

Local paravertebral mass

A local paravertebral mass may be caused by extraspinal invasion of a tumour.⁵

References

1. Fidler, M, Laminar removal and replacement: a technique for the removal of epidural tumour. Spine. 1988;13(2):218–221.

2. Plasmans, C, Van der Eycken, J, Laminar removal and replacement in combination with a spondylodesis in children with an intraspinal extension of a neuroblastoma. Spine. 1988;13(2):215–217.

3. Roblot, P, Alcalay, M, Cazenave-Roblot, F, Bontoux, D, Osteochondroma of the thoracic spine. Spine. 1982;7(1):240–243.

4. Constantini, S, Soffer, D, Siegel, T, Shalit, M, Paraganglioma of the thoracic spinal cord with cerebrospinal fluid metastasis. Spine. 1989;14(6):643–645.

5. Wells, F, Thomas, T, Matthewson, M, Holmes, A, Neurilemmoma of the thoracic spine. Spine. 1982;7(1):66–70.

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Disorders of the thoracic spine: Non-disc lesions

Disorders of the thoracic spine

Non-disc lesions

Introduction

Warning symptoms and signs

Symptoms

Progressively increasing pain

Expanding pain

Continuous pain, not changed by posture or activity

Increasing postoperative thoracic backache

First symptoms and signs in the thoracic area in patients over 50 years of age

Central pain radiating bilaterally around the thorax and spreading anteriorly towards the epigastrium

Signs

Gross limitation of both side flexions and rotations

Gross limitation of extension

Pain and limitation of side flexion away from the painful side as the only positive finding

Flexion with a rigid thoracic segment

Neurological signs

Muscle spasm

Local paravertebral mass

References

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Disorders of the thoracic spine: Non-disc lesions

Disorders of the thoracic spine

Non-disc lesions

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