This document discusses a case of a T1-T2 thoracic disc extrusion in a 50-year-old male presenting with severe radicular pain in the right arm. Conservative treatment was initially attempted with steroids, analgesics, and physical therapy providing some relief. Follow-up MRI two years later showed reduction in the size of the disc fragment without need for surgery. The document then reviews the literature on epidemiology, clinical presentation, diagnostic imaging, and surgical and non-surgical management of upper thoracic disc herniations.

1. T1 – T2 Thoracic Disc Extrusion
Vinod Naneria
Girish Yeotikar
Arjun Wadhwani
Choithram Hospital & Research centre,
Indore, India

2. Case History
• A 50 years Male,
• Acute onset of severe radicular pain right arm.
• The right arm is kept in 90 abduction.
• Unable to bring arm close to chest due to pain.
• Clinically there was no detectable neurological
deficit in any dermatome on right side. Planter
were down going.
• MRI was showing lateral extruded disc at T1 – T2
with proximal migration.

3. December 2010

4. December 2010

5. December 2010

6. Conservative Tx
• Rest
• Observation for any neurological deterioration
• Steroids
• Analgesics and Anti-acids
• Gabapentin + Methyl Cholamine (B12)
• Heat therapy with local rubrificient ointments.

7. Follow up - Aug 2012

8. Follow up - Aug 2012

9. Dec 2010 Aug 2012
D1
Disc fragment
D3
Disc

10. Dec 2010 Aug 2012
Disc fragment
Disc fragment

11. Follow up - Aug 2012
Disc fragment

13. Review Literature – Incidence & Site
• Thoracic disc herniation accounts for 0.15-4.4% of all disc
herniations.
• 75 % of all thoracic disc problems occur below T8, with a
peak of 26% at T11-12.
• The upper thoracic spine (T1-5) is the region least often
affected, with only 6% of all thoracic disc herniations
occurring here.
• To date, a total of 31 cases of T1-2 disc herniation have
been reported in the literature and all but one of these was
diagnosed by myelography, computed tomography (CT), or
CT myelography. Posterior surgical approaches were
performed in all except one case, in which an anterior
approach was used.
Magnetic Resonance Image Findings and Surgical Considerations in T1-2 Disc
Herniation
H. Caner, B.F. Kilinçoglu, S. Benli, N. Altinörs, M. Bavbek; Can. J. Neurol. Sci. 2003; 30:
152-154

14. Clinical presentation
• Upper thoracic disc herniation is rare. Patients
can easily be misdiagnosed with cervical disc
herniation or thoracic outlet syndrome.
• The common complaints in cases of this type are
pain in the arm, shoulder, and neck (60%), as well
as sensory (23%) and motor changes (18%).
• Radiculopathy is the most frequent finding (87%)
in published cases, and Horner.s syndrome is
seen in 21% of patients.
• Cervical MRI extended to include the upper
thoracic region is diagnostic.

15. Brown CW, Deffer PA Jr, Akmakjian J, et al:
The natural history of thoracic disc herniation.
Spine 17(Suppl):S97–S102, 1992
• Brown, et al.,6 retrospectively reviewed data obtained
in 55 patients with 72 thoracic disc herniations.
• They found that 15 (27%) of these patients eventually
required surgery, especially if they presented with signs
of myelopathy.
• The vast majority of patients, however, did not require
surgery and have continued to perform activities of
daily living, including vigorous sports activities.
• There was no correlation between radiographic
depiction and the patient’s symptoms.

16. operative treatment of thoracic discs
• Posterior approach - transpedicular,
transfacet;
• Posterolateral approach modified
costotransversectomy, lateral extracavitary;
• Anterolateral approach - transthoracic;
• Thoracoscopic approach
Thoracic herniated disc surgery is reserved for cases of
myelopathy, progressive lower extremity weakness, and
intolerable radicular pain that does not get better with
non-surgical treatments.

17. operative treatment of thoracic discs
• Sharan et al reported that anterior discectomy
without sternotomy.
• Rossitti et al reported an approach - anterior
discectomy with sternotomy.
• Total disc excision is not possible when posterior
or posterolateral approaches are used.
• posterior approaches, including laminectomy
with foraminotomies, laminectomy with
transdural disc excision, and thoracotomy with
lateral extracavitary exposure.

18. Disc herniation at T1–2
Report of four cases and literature review
Howard Morgan, M.D., M.A., and Christopher Abood, M.D.
Journal of Neurosurgery; January 1998 / Vol. 88 / No. 1 / Pages 148-150
• Intervertebral thoracic disc herniations are
uncommon and high thoracic disc herniations are
rare. In the upper third of the thoracic spine, T1–2 is
the most common level for disc ruptures.
• In reviewing the literature on thoracic disc
herniation, the authors found 27 cases at the T1–2
level, 23 of which were lateral disc herniations that
produced radiculopathy and four of which were
central disc herniations that caused myelopathy.

19. The anterior approach to high thoracic (T1-T2) disc
herniation; 1993, Vol. 7, No. 2 , Pages 189-192. By - Sandro Rossitti,
Hannes Stephensen, Sven Ekholm and Claes Von Essen
• A patient with a T1-T2 disc herniation, operated on via
the anterior approach, is presented. In a search of the
literature we found 18 reported cases, all operated on by
posterior or posterolateral approaches. The feasibility of
the anterior discectomy in our case was established by
preoperative magnetic resonance imaging of the upper
thorax. We think that an anterior discectomy at the level
of the upper thoracic spine can be easily performed in
selected cases. The clinical picture of T1 root
compression is described.

20. Neurologic manifestations of compressive radiculopathy of the first thoracic root
Kerry H. Levin, MD
From the Department of NeurologyCleveland Clinic Foundation, Cleveland, OH.
• Neurologic deficits in the first thoracic (T1) root
distribution are uncommon and not easily defined.
Myotomal charts indicate that distal arm and hand
muscles receive significant contributions from both the
C8 and T1 roots.
• A patient with focal T1 radiculopathy is presented who
demonstrated motor axon loss isolated to the abductor
pollicis brevis muscle. This finding provides another
source of evidence that the abductor pollicis brevis is
the primary T1 motor structure in the upper extremity,
improving precision in clinical and electromyographic
diagnosis.

21. Disc herniation at T1–2
Report of four cases and literature review
Howard Morgan, M.D., M.A., and Christopher Abood, M.D.
Journal of Neurosurgery; January 1998 / Vol. 88 / No. 1 / Pages 148-150
• The T-1 radiculopathy usually involves weakness of the
intrinsic muscles of the hand.
• The motor deficit of C-8 radiculopathy involves the intrinsic
muscles of the hand and most of the flexors and extensors
of the fingers and wrist.
• The T-1 radiculopathy may produce Horner's syndrome
(oculosympathetic paralysis) and diminished sensation in
the axilla, which are not found with C-8 radiculopathy.
• In clinical presentation as well as in treatment, the lateral
T1–2 disc herniation resembles a cervical disc herniation,
whereas the central T1–2 disc herniation displays the usual
appearance of a thoracic disc herniation.

22. High thoracic disc herniation. (PMID:3762895)
Alberico AM, Sahni KS, Hall JA Jr, Young HF
Neurosurgery [1986, 19(3):449-451]
• A case of T-1, T-2 disc herniation is reported. The
patient presented with diminished hand strength,
medial arm and shoulder pain, and medial arm,
forearm, and hand paresthesias.
• After surgical decompression and removal of a disc
fragment, the patient made a complete recovery.
• Routine cervical myelography was considered
inadequate in view of this patient's symptoms.
High thoracic myelography followed by computed
tomographic scanning should be considered for
patients with this presentation.

23. Thoracic intervertebral disc herniations: diagnostic value of
magnetic resonance imaging. (PMID:3173662)
Blumenkopf B
Department of Neurological Surgery, Vanderbilt University,
Nashville, Tennessee. Neurosurgery[1988, 23(1):36-40]
Thoracic disc herniation is relatively rare and frequently
poses a challenge in clinical diagnosis. These protrusions
have been categorized into two major anatomical types
and three main clinical syndromes. A number of
characteristic radiographic features have been reported.
Recently, magnetic resonance imaging (MRI) has gained
popularity as a neurodiagnostic imaging tool.
A series of nine cases of thoracic intervertebral disc
herniation is reported. The clinical aspects of the cases
are discussed, and the potential value of spine MRI for
thoracic disc herniation diagnosis is emphasized.

24. Eur Spine J. 1995;4(6):366-7.
First thoracic disc herniation with myelopathy.
Nakahara S, Sato T.
Department of Orthopaedic Surgery, Okayama University
Medical School, Japan.
• The case of a patient with progressive
paraparesis due to first thoracic disc
herniation is reported. He was treated
successfully with anterior interbody fusion by
the Smith-Robinson approach.
• An anterior approach is desirable for surgical
treatment of T1/2 disc herniation, and up to
this level the Smith-Robinson approach,
without thoracotomy, is entirely possible.

25. Awwad EE, Martin DS, Smith KR Jr, et al:
Asymptomatic versus symptomatic herniated thoracic
discs: their frequency and characteristics as detected by
computed tomography after myelography.
Neurosurgery 28:180–186, 1991
• Awwad, et al., in a retrospective review they
compared myelography studies obtained in
68 patients harboring asymptomatic
herniated thoracic discs with those obtained
in five patients harboring symptomatic
thoracic herniated discs.

26. References
• Rossitti S, Stephensen H, Ekholm S, von Essen C. The anterior
approach to high thoracic (T1-T2) disc herniation. Br J Neurosurg
1993; 7:189-192.
• Winter RB, Siebert R. Herniated thoracic disc at T1-T2 with
paraparesis. Transthoracic excision and fusion - case report with 4-
year follow-up. Spine 1993; 18:782-784.
• Hamlyn PJ, Zeital T, King TT. Protrusion of the first thoracic disc.
Surg Neurol 1991; 35:329-331.
• Korovessis PG, Stamatakis M, Michael A, Baikousis A. Three-level
thoracic disc herniation: case report and review of the literature.
Eur Spine J 1997; 6:74-76.
• Kumar R, Buckley TF. First thoracic disc protrusion. Spine 1986;
11:499-501.
• Morgan H. Abood C. Disc herniation at T1-2. J Neurosurg 1998; 88:
148-150.

27. References
• Gelch MM. Herniated thoracic disc at T1-2 level associated with
Horner.s syndrome. Case report. J Neurosurg 1978; 48:128-130.
• Hammon WM. Extruded upper thoracic disc causing Horner.s
syndrome. Report of a case. Med Ann Dist Columbia 1968; 37:541-
542.
• Lloyd TV, Johnson JC, Paul DJ, et al. Horner.s syndome secondary to
herniated disc at T1-T2. AJR Am J Roentgenol 1980;134:184-185.
• Sharan AD, Przybylski GJ, Tartaglino L. Approaching the upper
thoracic vertebrae without sternotomy or thoracotomy: a
radiographic analysis with clinical application. Spine 2000;
• 25:1910-1916,
• Nakahara S, Sato T. First thoracic disc herniation with myelopathy.
Eur Spine J 1995, 4:366-367

28. DISCLAIMER
Information contained and transmitted by this presentation is
based on personal experience and collection of cases at
Choithram Hospital & Research centre, Indore, India, during
last 32 years. It is intended for use only by the students of
orthopaedic surgery. Views and opinion expressed in this
presentation are personal opinion. Depending upon the x-
rays and clinical presentations viewers can make their own
opinion. For any confusion please contact the sole author for
clarification. Every body is allowed to copy or download and
use the material best suited to him. I am not responsible for
any controversies arise out of this presentation. There is no
direct or indirect involvement of finances in preparation of
this presentation. For any correction or suggestion please
contact naneria@yahoo.com