Cervical and Thoracic Discogenic Pain

Chapter 10 Cervical and Thoracic Discogenic Pain

Therapeutic Nonsurgical Options

Chapter Overview

Chapter Synopsis: Although the predominant therapies for discogenic pain involve surgery, nonsurgical alternatives are increasingly becoming available. This chapter surveys these techniques with a focus on cervical and thoracic discogenic pain. The most conventional of these options is injection of steroids into the disc; outcomes evidence is mixed. Annuloplasty and nucleoplasty use radiofrequency technique to modify disc tissue. Some other less conventional techniques have been used only in lumbar spine. For example, biochemical ablation can be achieved by injecting the enzyme papain, which digests the proteoglycan molecule. Ozone injection is thought to relieve inflammation by improving microcirculation in the disc, and injection of methylene blue has been shown to relieve lumbar discogenic pain by destroying sensory nerve endings. Development and improvement of nonsurgical interventions for discogenic pain is likely to continue in the coming years.

Important Points:

Cervical and thoracic discogenic pain is far less studied than lumbar disease.

Interventional treatment for cervical and thoracic disc disease is largely anecdotal.

Clinical Pearls:

Cervical discography is approached from the anterior right side.

Thoracic discography involves advancing the needle into the center of the disc on a course that bisects the two articulations of the head of the rib.

Clinical Pitfall:

Myelopathic symptoms such as bowel and bladder changes, lower extremity weakness, altered balance, and hyperreflexia point toward significant central disc herniation.

Cervical and Thoracic Discogenic Pain

Neck pain is a near ubiquitous complaint. Fortunately most neck pain is self-limited. Neck pain that limits activities is not uncommon, with 12-month prevalence estimates ranging from 2% to 11%.¹ However, when neck pain becomes chronic, diagnosis of the pain generator may prove difficult. The source is more obvious when accompanied by radicular symptoms. The source of axial neck pain is often limited to myofascial, facetogenic, discogenic, and often a combination of all three.² Posterior thorax pain is a much rarer entity than cervical and lumbar pain. A common cause of thoracic back pain is reflex muscle spasm radiating from an original lumbar pain source. Thoracic discs, facets, and myofascia are all possible sources of upper to midback pain. Of discogenic pain complaints 36% are of cervical origin, compared to only 4% in the thoracic regional. Obviously the remaining 62% involve the lumbar region.^3,⁴

Clinical Presentation

Discogenic neck and upper back pain usually manifests in axial pain that may progress to involve radiculopathy. The disc may herniate, resulting in compression of the adjacent nerve root or cord segment. It may manifest an annular fissure (Fig. 10-1), resulting in chemical irritation of the adjacent nerve root or cord segment. The disc itself may prove painful, with neoinnervation of the annulus. History elements that suggest discogenic pain in the neck include pain with flexion, prolonged sitting, and protruded head positions. Physical examination findings that suggest cervical discogenic pain include decreased range of motion (ROM) and referred pain patterns (Fig. 10-2).⁵ If radiculopathy is present, compression tests such as the Spurling and shoulder abduction tests have a high specificity but low sensitivity.⁶ Sensory, motor, and reflex tests are helpful in cervical radiculopathy diagnosis. Myelopathic symptoms such as bowel/bladder changes, lower-extremity weakness, altered balance, and hyperreflexia point toward significant central disc herniation.

Fig. 10-1 Posterior view. Pain caused in varying distributions secondary to provocative cervical discography.

Adapted from Grubb SA et al: Cervical discography: clinical implications from 12 years of experience, Spine 25:1382-1389, 2000.

Fig. 10-2 Cervical discography. Lateral fluoroscopic view demonstrating a posterior annular tear at C4-C5 with epidural leak of the contract and a normal nucleogram at C5-C6.

History elements that suggest thoracic discogenic pain are similar: flexion, prolonged sitting/standing, and Valsalva maneuvers. Physical examination findings that suggest thoracic discogenic pain manifestation include decreased ROM and referred pain patterns. Thoracic radiculopathy may manifest in altered sensory testing; however, motor and reflex testing is not readily interpreted. Visceral complaints have been manifestations of thoracic disc herniations often diagnosed only after an extensive cardiac, pulmonary, and gastrointestinal workup.

Tags: and Treatment of Discogenic Pain Volume 3, Diagnosis Management

Jun 14, 2016 | Posted by admin in PAIN MEDICINE | Comments Off

Full access? Get Clinical Tree

Get Clinical Tree app for offline access

Get Clinical Tree app for offline access