Thoracic Spine: Pathologies and Referral Patterns

Objectives

• Understand common referral patterns in the thoracic spine.
• Understand common thoracic pathology.

Overview of Pathologies

• Visceral pathology.
• Thoracic Outlet Syndrome.
• Scoliosis.
• Rib strain/sprain.
• Costochondritis.
• Myofascial Strain/Pain.
• Compression Fracture.
• Scheuerman’s Disease (Juvenile Kyphosis).

Visceral Pathology

• The T-spine is a common area for referral from viscera due to connections with the sympathetic chain ganglion.
• Awareness and screening for non-mechanical pain is crucial.

Cardiac Ischemia

• Includes a history of risk factors for CAD and MI.
• Symptoms also include angina and nausea.

Dissecting Thoracic Aneurysm

• Characterized by sudden, severe, and unrelenting chest pain that can radiate to the upper back.
• symptoms are unrelieved with laying down.

Peptic Ulcer

• Causes a boring (drilling) pain from the epigastric area to the middle thoracic spine.
• Pain is triggered or relieved by meals and there may be a history of NSAID use.
• A perforated ulcer can refer pain to the shoulder with irritation of the diaphragm.

Cholecystitis

• Presents as right upper quadrant and scapular pain.
• Includes fever, nausea, and vomiting.
• Pain presents 1-2 hours after a fatty meal

Renal Infection and Kidney Stones

• Causes renal colic/flank pain, fever, nausea, and vomiting.
• Increased risk for kidney infection with ongoing UTI.

Neoplastic Conditions

• Considerations include age over 50 years and previous history of cancer.
• Presents as unexplained weight loss, constant pain with no relief with bed rest, and night pain.

Inflammatory Disorders

• May be Ankylosing Spondylitis with limited chest expansion (less than
• Characterized by peripheral joint involvement and positive HLA-B27 blood test.

Inflammatory or Systemic Disease

• Temperature > 100°.
• Blood Pressure >160/95mmHg.
• Resting Pulse > 100 bpm.
• Resting Respiration > 25 bpm.
• Includes fatigue, osteomyelitis, diskitis, epidural infection, and pericarditis.

Thoracic Outlet Syndrome (TOS)

• TOS involves compression and/or irritation of structures going down the arm.
• Can be neurogenic (nTOS), arterial (aTOS), or venous (vTOS).
• Neurogenic TOS affects the brachial plexus.
• Arterial TOS affects the subclavian artery.
• Venous TOS affects the subclavian vein.
• Approximately 8% of the population is reported to have TOS.
• Higher incidence of TOS on females than males.
• Neurogenic TOS is more common.
• Bony pathologies such as cervical ribs or remodeling after clavicle/1st rib fracture are possible causes.
• Overuse and postural considerations contribute to TOS.

TOS Signs and Symptoms

• Neurogenic TOS presents with paresthesia, pain, hand and UE weakness, with possible “hard” neuro signs that are consistent or intermittent.
• Arterial TOS presents with paresthesia, upper extremity ischemia, claudication, and decreased pulse.
• Venous TOS is characterized by upper extremity edema, cyanosis, and paresthesia.

TOS Treatment

• Conservative treatment includes manual therapy (1st rib, T-spine, muscles), exercise (mobility, strengthening), and postural modification.
• Treatment options may include injections and surgery specifically, 1st rib or cervical rib resection.

Scoliosis

• A spinal deformity resulting in one or more lateral curves, including rotation of vertebral segments.
• Bracing can slow or stop the curve but cannot correct it
• Surgical intervention is considered for 40-45 degree curves in growing children, or 50-60 degree curves in the skeletally mature.
• Physical therapy can improve function and pain but will not change or correct the curve.

Rib Sprain/Strain

• Usually results from trauma, such as quick twisting movements, blunt force, or falls.
• Symptoms include pain in the thoracic region, can radiate laterally and anteriorly as achy or sharp pain, difficulty taking deep breath, painful coughing/sneezing, and limited rotation and/or lateral flexion.
• Treatment includes time, conservative management (manual, mobility, strengthening), or injection if chronic.

Costochondritis

• Inflammation of costochondral joints.
• Is generally idiopathic, found in adults aged 40-50.
• Is more common in females, and generally self-limiting, but can produce chronic pain.
• Presents as anterior chest pain, pain with trunk movements, deep breaths, and coughing, and tenderness to palpation of the costochondral joints.
• Serious causes of pain such as myocardial infarction, pericarditis, pneumothorax, aortic dissection, and pulmonary embolism must be ruled out
• Treatment includes pain modulation (medication, manual therapy) and gentle exercise (relative rest).

Myofascial Strain/Pain

• Causes include trauma (quick movements, blunt force), overuse (extended time in a posture, too rapid increase in activity), and connective tissue disorders.
• Signs and symptoms include tenderness to palpation, generalized ache, burning, sharp, tight symptoms, and aggravation by movement/use.
• The condition is generally self-limiting but is one of the most common types of chronic pain.

Compression Fracture

• Common in postmenopausal women due to higher rates of osteoporosis.
• Usually due to trauma, often seemingly minor (e.g., bending over, coughing) and due to long-term glucocorticoid use.
• Signs and symptoms include "Dowager Hump"- Extreme kyphotic curve, severe, localized pain (occasionally no pain), and pain in the area overlying the affected segment.
• Treatment includes time/pain modulation, strengthening extensors, vertebroplasty, but cannot reverse the kyphosis.

Scheuermann’s Disease

• Rigid hyper-kyphosis most often seen in adolescents where males are more affected than females.
• Spinal fusion is indicated for >75 degree angle, neurologic deficits/spinal cord compression, and severe refractory pain.
• The condition can be non-painful and might predispose to myofascial pain, but evidence is uncertain.
• Treatment options: Exercise and physical therapy, Bracing,