Thoracic Myelopathy

Conditions Treated

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Overview

Thoracic myelopathy is compression of the spinal cord in the mid-back (thoracic spine), most commonly caused by a large or calcified thoracic disc herniation pressing on the cord from the front, or by posterior compression from thickened ligaments and bone spurs. Because the thoracic spinal canal is naturally narrow, even moderate compression can significantly impair cord function. Early recognition and treatment are important to prevent irreversible neurological decline.

Symptoms

Progressive leg weakness, heaviness or stiffness — often worse when walking.
Gait disturbance or balance problems; difficulty climbing stairs or walking on uneven ground.
Numbness, tingling or a “band-like” tightness around the trunk or legs.
Spasticity (muscle stiffness or spasms) in the legs.
In more advanced cases, bladder dysfunction (urgency or difficulty passing urine) or bowel changes.
Back or chest pain may be present but is often mild or absent.

Thoracic myelopathy typically develops gradually and may be mistaken for other conditions; any progressive neurological symptoms warrant urgent assessment.

Causes

Giant or calcified thoracic disc herniation: a large disc pressing on the spinal cord from the front — one of the most common and surgically challenging causes.
Posterior compression: thickened ligamentum flavum, bone spurs or facet joint hypertrophy narrowing the canal from behind.
Ossification of the posterior longitudinal ligament (OPLL) or ligamentum flavum: calcification of spinal ligaments causing progressive cord compression.
Thoracic spinal stenosis: narrowing of the spinal canal from degenerative changes, affecting the cord.
Less commonly, tumours, fractures, infection or vascular malformations can cause thoracic cord compression.

Diagnosis

Accurate diagnosis is essential as thoracic myelopathy can be subtle and is often delayed. It requires a combination of clinical assessment and imaging.

Neurological examination: testing leg strength, reflexes (including hyperreflexia and pathological reflexes such as Babinski sign), sensation, coordination and gait.
MRI: the primary imaging tool — demonstrates the level and extent of cord compression, disc herniation, calcification and any cord signal change (indicating injury).
CT scan: particularly important for identifying calcified or ossified discs, and for surgical planning.
CT myelography: may be used when MRI is contraindicated or when additional detail about compression is needed.
X-rays: assess spinal alignment and degenerative changes.

Non‑surgical treatment

Conservative management has a limited role in thoracic myelopathy, as the underlying cord compression does not resolve without surgery. It may be considered in very mild or stable cases, or while awaiting surgical intervention.

Activity modification: avoiding activities that may worsen symptoms, such as heavy lifting, prolonged standing or high-impact exercise.
Medications: anti-inflammatories and neuropathic pain medicines to manage symptoms, though they do not treat the underlying compression.
Physiotherapy: gentle exercise to maintain mobility, strength and balance; walking aids if gait is affected.
Close monitoring: regular clinical review and repeat imaging to detect any deterioration and guide the timing of surgery.

Given the risk of progressive and potentially irreversible cord injury, non-surgical treatment is generally not appropriate for moderate-to-severe thoracic myelopathy.

Surgical treatment

Surgery is the primary treatment for thoracic myelopathy and is recommended for most patients with moderate-to-severe symptoms or any evidence of neurological deterioration. The surgical approach depends on the cause and location of compression.

Thoracotomy (anterior approach) for giant thoracic disc: for large or calcified disc herniations compressing the cord from the front, an anterior approach through the chest (thoracotomy) allows direct removal of the disc with minimal cord manipulation — this is the preferred approach for giant calcified thoracic discs.
Posterior decompression and fusion: for posterior compression from thickened ligaments, bone spurs or facet joint changes, removal of posterior bony and ligamentous elements (laminectomy or laminoplasty) decompresses the cord from behind. Fusion is often added to maintain spinal stability.
Minimally invasive or video-assisted thoracoscopic surgery (VATS): in selected cases, a thoracoscopic approach may be used for anterior disc removal, reducing the invasiveness of the thoracotomy.
Combined anterior and posterior surgery: some cases with complex or multilevel compression may require both approaches to achieve adequate decompression and stabilisation.

Early surgery generally leads to better neurological outcomes; delayed treatment may result in permanent deficits due to prolonged cord compression.