Thoracic disc herniation

In one minute

A thoracic disc herniation is a disc in the middle of the back (the twelve vertebrae that carry the ribs) that has pushed backward toward the spinal cord. Most are found by chance on an MRI (magnetic resonance imaging) scan and cause nothing. The few that cause symptoms produce band-like chest or back pain or, when the cord is pressed, numb and clumsy legs. MRI shows it; a CT scan (computed tomography, an X-ray based scan that shows bone well) shows whether the disc has hardened with calcium. Silent herniations are left alone, painful ones are treated with time, physiotherapy and injections, and those that press on the cord are treated surgically, often endoscopically, which in our practice means a 7 mm incision.

What it is

Between the thoracic vertebrae sit the discs, a soft core inside a tough ring. A herniation means the ring has torn and part of the core has moved backward into the canal where the spinal cord runs. The thoracic canal is narrow and the cord fills much of it, so a herniation here has less room to be harmless than one in the low back.

Symptomatic thoracic herniations are rare: a 2023 review puts them at under 1% of all disc herniations, and a 2026 systematic review estimates 0.25 to 1%. Silent ones are common. When 90 people with no thoracic symptoms had a thoracic MRI, 37% had a herniated disc and 29% had some flattening of the cord. Two features set thoracic herniations apart. Many have calcified (about 30% of the endoscopically treated discs in the 2026 review were calcified or partially calcified), meaning the displaced disc has hardened into bone-like tissue that can stick to the dura, the membrane around the cord. And the main danger is myelopathy (damage to the spinal cord itself) rather than the sciatica-type nerve pain of a lumbar disc.

Causes and risk factors

Most thoracic herniations grow out of ordinary wear. The core dries out with age, the ring weakens, and a lift, a twist or a fall pushes material through. A minority follow a clear injury. In the surgical series collected by the 2026 review the average age was about 53, and in the 2023 meta-analysis just over half of operated patients were men. The general risk factors for disc degeneration, smoking, heavy lifting and family history, are assumed to apply, but there is no thoracic-specific evidence, and we would rather say so than invent a figure.

How it develops

The displaced disc can do one of three things. It can sit in the canal without touching anything important, which is the common case. It can press on the nerve root leaving at that level, which sends pain around the chest wall along the rib. Or it can press on the cord, whose blood supply in the mid-thoracic segment is thin, so that sustained compression produces numbness, stiffness and weakness in the legs and, later, bladder trouble. Calcified herniations most often reach this stage, because they are rigid, sit in the midline in front of the cord and can become adherent to the dura.

Silent herniations rarely turn dangerous. When 20 people with 48 symptom-free thoracic herniations were rescanned after an average of 26 months, all were still symptom-free; the small herniations had mostly stayed the same and the large ones had often shrunk.

Symptoms

The story follows one of three patterns, sometimes mixed. The first is pain in the mid back that wraps around the chest or abdomen in a band, worse with coughing, twisting or lying flat: the herniation is touching the nerve root, which is called thoracic radiculopathy. The second is myelopathy: heavy, numb or clumsy legs, a wide and unsteady walk, difficulty on stairs, sometimes a tight band around the trunk, and in advanced cases bladder or bowel difficulty. The third is pain in the mid back alone. Band-like chest pain can mimic heart, lung or stomach disease; the clue is that it follows a rib, changes with spine movement and often comes with altered skin sensation in the same strip.

Diagnosis

The examination comes first: strength and sensation in the legs, the reflexes (brisk reflexes point to the cord), the strip of numbness on the chest wall, and the way you walk.

MRI is the standard test. It shows the disc, the cord and whether the cord signal has changed, which is a sign of injury. Because thoracic herniations are often calcified and MRI shows calcium poorly, a CT scan is usually added before any operation to show how hard the fragment is. Words in the report: protrusion (the core bulges but the ring holds), extrusion (the core has broken through), central or paracentral (in the midline or just to one side), calcified, and "cord signal change" or "myelomalacia", which mean the cord has been affected. For our opinion, send the report and the images that show the herniation with a short note on your symptoms and how long you have had them.

Treatment without surgery

A herniation found by chance, with no matching symptoms, needs no treatment and no follow-up scans unless symptoms appear.

For pain without cord signs, the first step is time and movement: staying active within pain limits, a short course of anti-inflammatory medication (NSAIDs; the doctor chooses the drug and the dose) and physiotherapy for trunk strength and posture. A nerve root injection under X-ray guidance can settle radicular chest pain and doubles as a test: if the pain disappears while the anaesthetic works, the disc is confirmed as the source. Many people with pain alone improve over weeks to months; the literature gives no reliable percentage because the condition is rare, but it is clear that non-surgical care is not the right path once the cord is involved.

When surgery is considered

Surgery is considered for myelopathy, meaning signs of cord compression on examination, especially if worsening, because the aim is to stop the damage before it becomes permanent; for radicular or axial pain still disabling after 6 to 12 weeks of proper conservative care when the MRI shows a herniation at the matching level; and for a large herniation compressing the cord with signal change on MRI, even when symptoms are mild.

The surgical reviews agree that progressive myelopathy is the strongest indication and that decompressing the cord before a severe deficit has set in gives the better result. In the systematic review of giant calcified discs, where 145 of 164 patients had myelopathy, neurological grade improved after surgery in 69%, stayed the same in 22% and worsened in 3%. Surgery usually helps, sometimes only stabilises, and occasionally harms.

Surgical options

Full endoscopic thoracic discectomy works through a skin incision of under a centimetre (the published series describe an 8 mm incision; ours is 7 mm), a working channel and a camera, usually entering through the foramen from the side and back (the transforaminal route). It suits soft and partially calcified herniations that sit to one side of the midline. A 2026 systematic review of 23 studies and 695 patients, pooling separate endoscopic and open series rather than a randomised comparison, found that endoscopic surgery took 82 versus 201 minutes on average, lost 19 versus 355 mL of blood, needed fusion in 1.4% versus 94% of cases and kept patients in hospital about 2.7 versus 10.5 days, with similar pain and function results. About 44% of the endoscopic patients had myelopathy and about 30% had calcified or partially calcified discs. See the endoscopic thoracic discectomy page.

Posterolateral open approaches remove part of the facet joint or rib head to reach the disc from behind, for lateral fragments when the endoscope is not suitable. Anterior approaches, through the chest, give a direct view of the front of the cord; the 2018 systematic review recommends the anterior thoracotomy approach for giant calcified discs, and the 2026 review of calcified herniations favours anterior or anterolateral access for central, giant, densely calcified lesions. Fusion is added when enough bone has been removed to make the segment unstable, which is common after open surgery and rare after endoscopic surgery.

How we treat it at spine.uz

We are Tashkent's first endoscopic spine team, five surgeons operating as one, and we operate on all levels of the spine including the thoracic segment. The first step costs nothing: send your MRI and CT images through Telegram or WhatsApp and a doctor from the team replies by voice within 48 hours.

When an operation is indicated and the fragment is suitable, we use the full endoscopic approach through a 7 mm incision. Most of our endoscopic decompressions are done under local anaesthesia with sedation; the anaesthetist and the surgeon decide this for each patient. Endoscopic decompression uses no screws or implants. Most patients walk on the day of surgery and go home within 24 hours. When a giant, calcified, central herniation needs an open approach instead, we say so. After the consultation you receive a written conclusion from the team. Across the team's 27,600+ endoscopic and spine operations, our complication rate is well below 1%.

Recovery and outcomes

After endoscopic thoracic discectomy, walking begins the same day. In the series pooled by the 2026 review, the average hospital stay was about 2.7 days after endoscopic surgery and 10.5 days after open surgery. Radicular pain often eases immediately; myelopathy recovers more slowly, over months, and more fully when the deficit was mild and short-lived before surgery.

The complication figures for full endoscopic thoracic discectomy come from a 2023 meta-analysis of 13 studies and 285 patients: dural tear 1.3%, temporary altered sensation 4.7%, recurrent herniation 2.9%, postoperative myelopathy 2.1%, epidural haematoma 1.1% and reoperation 1.7%, with no infections or deaths reported. The 2023 Neurospine review cites an early series in which 5 of 25 patients (20%) had a complication, and notes that for minimally invasive spine surgery in general operative time and complications settle after roughly 20 to 30 cases, so it is fair to ask any surgeon about their experience with this operation.

Living with it and prevention

There is no proven way to prevent a thoracic disc from herniating. What is supported for the spine in general: not smoking, keeping the trunk muscles strong, lifting with the legs rather than the back, and keeping a healthy weight. A known silent herniation does not need you to restrict your life, but tell a doctor promptly if your walking changes, your legs go numb or your bladder control alters.