A 34-yr-old woman with back pain, right chest pain, and difficulty walking that started 15 days earlier while doing housework was evaluated. She reported that her household duties frequently including pushing and lifting heavy objects. Her physical examination revealed spasm of the thoracic and lumbar paravertebral muscles, hypalgesia below the T8 dermatome and decreased lower-limb muscle strength (Medical Research Council Grade 4/5). She had hyperactive reflexes at the knees and ankles, a positive Babinski sign, ankle clonus, and grade 2 spasticity (modified Ashworth scale), with no pathological findings in the upper limbs. She also reported urge incontinence.Magnetic resonance imaging showed an extruded disk at T2Y3, protruded disks at T3Y4, T4Y5, and T5Y6 with mild spinal cord compression, and extruded disks at T7Y8, T8Y9, T9Y10, and T10Y11 with severe spinal cord compression (Fig. 1). Symptomatic multilevel thoracic disk herniations with myelopathy was diagnosed. Disk herniations were seen at eight of the 12 thoracic levels, and the extruded disks at T7Y8 and T8Y9 were thought to be symptomatic. The patient was referred for surgical intervention but preferred conservative management. She was subsequently lost to follow-up.Thoracic disk herniation (TDH) occurs much less frequently than cervical or lumbar disk herniation, and multiple TDHs are rare. The symptoms and signs are usually slowly progressive and are not strongly associated with the herniated disk position, level, composition, or size. 1 TDH accounts for only about 0.25%Y0.75% of all symptomatic herniated disks and about 0.15%Y1.8% of surgically treated disk herniations. Most TDHs are found in the lower thoracic spine, with more than 75% occurring below T8, mainly at T11Y12, probably related to weakness of the posterior longitudinal ligament and the hypermobility of the lower thoracic segment. 1,2 In a study of 78 cases of TDH, 26% of the patients had herniations at multiple levels, and 12% had disk protrusions at noncontiguous levels. 3
