Thoracic Spine Procedures
The thoracic spine contains 12 thoracic vertebra. Degenerative conditions such as herniated discs and spinal stenosis rarely occur in the thoracic spine. The major reason that there is less arthritis in the thoracic spine is that it is much less mobile than the cervical or lumbar regions because it is fixated by the rib cage. Pathologic conditions that more commonly affect the thoracic spine include tumors, trauma, and infection which we treat in conjunction with our physician colleagues (oncologists, infectious disease specialists, and orthopaedic surgeons).
A compression fracture of the thoracic vertebra is a common condition that typically afflicts elderly people with underlying osteoporosis. Conditions such as osteoporosis and chronic steroid use can predispose to fragile bones which can lead to a fracture of the vertebra. Fractures occur most commonly in the thoracic area but can also occur in the lumbar spine. The fracture can result from a fall or from even minor trauma such as twisting or turning. Localized back pain is the usual result of a compression fracture. The pain is usually brought on with minor positional movements and can be fairly debilitating. In the past, the treatment for these compression fractures included pain medications (usually narcotics), bed rest, and bracing. Narcotics are frequently poorly tolerated by the elderly and can lead to nausea, constipation, confusion, and oversedation which can further increase the risk of falling. Bracing can be cumbersome and most patients will avoid wearing the brace. Bedrest can lead to further muscle weakness and wasting. Kyphoplasty is a technique developed within the last 10 years that has been effective in dealing with compression fractures.
Kyphoplasty involves the injection of cement into the fractured vertebra with the goal of relieving pain associated with the fracture and also preventing the fractured vertebra from further collapse which can lead to further spinal instability. This minimally-invasive procedure treats spine fractures caused by osteoporosis. It is designed to provide rapid back pain relief and help straighten the spine. Utilizing fluoroscopy, the compressed vertebra is visualized allowing for the precise placement of cement into the vertebra using a specialized delivery cannula. Prior to delivery of cement, a small balloon is inflated into the vertebral body allowing for some reduction of the compression on the vertebra and providing a target for cement delivery and at the same time providing more compact bone at the peripheral edge of the vertebral body. The procedure is well tolerated by the elderly since it is performed percutaneously and therefore not requiring the destruction of bony and soft tissues for access to the fractured vertebra. Patients usually go home on the following day and usually experience a significant reduction in their pain level.
The thoracic spine is a common location for spinal cord stimulation. Spinal cord stimulation is a technique whereby electrodes are placed in the spinal canal adjacent to the spinal cord to deliver electrical stimulation to the region of the spinal cord with the aim of blocking the transmission of pain signals from the back, arms and legs. One of the major functions of spinal cord stimulation is to treat a condition known as neuropathic pain. Neuropathic pain is a complex chronic pain state usually accompanied by neural injury. As a result of the neural injury, there is faulty transmission of pain even though there is no active compromise of the nerve by other structures such as disc or bone spurs. The pain is usually felt as "burning or throbbing" and is typically constant and sometimes worsens at night time. Neuropathic pain can be a common byproduct of a damaged nerve that was initially compromised by a disc or bone spur or other form of trauma. Surgery may have been successful in decompressing the extrinsic pressure on the nerve, however, the nerve does not completely heal after the compression is alleviated and thus results in a state of chronic pain as a result of the damaged nerve. This scenario commonly referred to as "failed back surgery syndrome" may be amenable to spinal cord stimulation.
The treatment of neuropathic pain includes medications and spinal cord stimulation. Various medications have been tried to treat neuropathic pain with the most common medications being neurontin, cymbalta, and lyrica. If pain is refractory to pain medications, then spinal cord stimulation is a reasonable option. A spinal cord stimulation trial is first done to determine if the pain is responsive to stimulation. It involves the placement of a lead into the spinal canal and externally connected to a battery. It allows for the patient to experience the degree of pain relief for several days. If there is significant pain reduction then a permanent spinal cord stimulator is placed. A spinal cord stimulator consists of an electrical lead that is connected to a wire which is connected to a small generator/battery typically at the level of the hip. The procedure usually takes 1-2 hours and usually will require one night stay in the hospital. The goal of a spinal cord stimulator is to reduce pain and therefore to reduce or eliminate use of narcotics and allow for greater functional capacity.