Thoracic Spine: Metastatic Cancers & Fractures

Metastatic Cancers and Thoracic Spine Pain

• Metastatic cancers have a predilection for the T-spine.
• Internal organ issues can manifest as pain referred to the T-spine.
• It is important to consider the overall health of the patient when addressing T-spine pain.

Compression Fractures

• Often result from falls from a height landing on the buttocks or feet.
• More common in young males and older females.
• Wedge fractures occur when the spine is flexed and stable, often seen in elderly women; treatment includes bed rest, AROM, TLSO for severe cases, or kyphoplasty.
• Burst fractures occur when the spine is straight and stable, often comminuted; commonly seen in young men falling from a high height; treatment includes bed rest, TLSO, or surgery for chronic LBP.

Rib Fractures

• Typically caused by direct trauma.
• Very painful, even with minimal movement like breathing.
• Can lead to complications from injury to internal organs.
• Typically treated non-surgically with an abdominal binder to reduce breathing movement.
• ORIF is necessary for serious cases, such as those caused by high energy trauma; flail chest may occur if two or more ribs are detached.

Ankylosing Spondylitis

• A genetic rheumatologic disorder.
• Typically affects young males in their late teens to 30s.
• Men often experience a more severe form than women, while women tend to have a more atypical presentation.
• Presentation commonly involves a young teenage boy with SI/T spine joint pain, skipping the lumbar region and going straight to the T-spine.
• Radiographs and family history are necessary for diagnosis.
• In advanced cases, ligaments ossify, leading to fusion of the T-spine and then the L-spine.
• No cure exists, focus is on ensuring the bones ossify straight; treatment includes maintaining an upright posture and extension exercises.

Scheuermann’s Disease

• Affects young males aged 13-16, often during puberty.
• Characterized by growth abnormalities of the anterior epiphyseal end plate, resulting in weak vertebral bodies and disc herniation.
• Schmorl's nodes are a pathognomonic finding.
• Leads to kyphosis from vertebral body wedging.
• Patients have difficulty standing up straight actively but can do so passively.
• Treatment involves surgery, TLSO, and extension exercises.

Costochondritis

• An inflammatory reaction at the costochondral/sternochondral junction.
• Patients typically present with morning chest pain, often exacerbated from forced exhalation, like laughing or coughing.
• Palpation and MMT should be performed.
• A systems review should be done to rule out other systemic problems.

Tietze’s Syndrome

• Characterized by swelling of synovial junctions.
• Nodules are absent unlike in costochondritis.
• Nodules may be able to palpated.
• Treatment is generally conservative.
• Palpation and MMT should be performed.
• Should rule out other systemic problems.

Chest Deformities

• Impair respiratory function, upper extremity movement, and posture.

Pectus Carinatum

• Sternum projects too far anteriorly and inferiorly.
• Increases the anterior-posterior dimension of the chest.
• Treated with bracing or other conservative methods.

Pectus Excavatum

• Sternum is too far posterior, limiting space for internal organs and is more common in young boys.
• The heart may be displaced inferiorly and laterally, decreasing tidal volume.
• Surgery typically required; the AP dimension of the chest is decreased.

Barrel Chest

• Sternum projects anteriorly and superiorly, increasing the AP diameter of the chest.
• Often a result of COPD.
• Commonly seen with emphysema.

Scoliosis

• More common in young women.
• Can be congenital or idiopathic, with idiopathic being more common.
• Scoliosis named by convexity and spinal level; a right thoracic scoliosis is convex on the right.
• Skyline View is often used
• Structural scoliosis involves bony deformity, remains the same when bent over, and may require surgery.
• Non-structural scoliosis is postural, disappears when bending over, and is treated with stretching and strengthening exercises.

Patient Examination

• Differential diagnosis of thoracic pain can be difficult due to biomechanics, organ proximity, and articulations.
• Pain from the axial spine can mimic cardiac, pulmonary, renal, or visceral conditions.
• Important to rule out serious conditions.
• Offloading/loading a small suspected tumor in the thoracic region can mimic a sprain or strain.
• Pain should be constant.
• Musculoskeletal origin typically alleviates with movement or posture.
• Pleuritic, cardiac, or rib dysfunction increases with respiration or exertion; could be costochondritis with increased activity.
• Gastric pain could originate from eating/drinking, can be referred to the T-spine.
• Determine the exact location of pain through palpation; differentiate between MSK and pleural pain.
• Assess vitals during the examination, noting any increase in heart rate.
• Observe for kyphosis, frontal/transverse plane abnormalities, muscle symmetry, bony structure relationships, and chest wall shape.

Acute Phase Goals

• Decrease pain, inflammation, and muscle spasm.
• Promote tissue healing and increase pain-free range of motion.
• Regain soft tissue extensibility and neuromuscular control.
• Initiate postural education and promote correct breathing.
• Educate the patient on activities to avoid and positions of comfort.
• Includes AROM and PROM.

Intervention: Functional Phase Goals

• Include reducing patient's pain.
• Restore full vertebral and costal ROM.
• Integrate the upper and lower kinetic chains.
• Restore respiratory function by tracking oxygen saturation and heart rate, also strength, and neuromuscular control.
• Build towards functional goals.