September 5 th – 8 th 2013 Nottingham Conference Centre, United Kingdom www.nspine.co.uk

Thoracic Disc Disease

 Most common location is at T/L junction & T8-12.

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Herniated disc

Upper back pain, radiating pain & numbness.

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Degenerative disc disease

Conceptually similar to lumbar and cervical disc disorders, but symptomatic lesions are far less common.

Disc pathology presentation

 Often no symptoms!

 Isolated upper back pain which may radiate in a dermatomal pattern.

 Muscle spasm & change in posture in thoracic area.

 Pain exacerbated by coughing, sneezing or twisting.

 May present with myelopathy  bowel or bladder dysfunction.

sensory disturbances e.g. numbness, below level of compression, difficulty with balance & walking, lower extremity weakness, or

Differential Diagnosis

 Radiating pain may be perceived to be in chest or abdomen. Therefore need to assess heart, lungs, kidney & GI disorders to exclude non-musculoskeletal causes.

 DD: Spine fracture (e.g. osteoporotic), infection, tumour & certain metabolic disorders.

Thoracic Disc Disease

In a study by Wood et al (1995)* 90 asymptomatic patients were scanned with MRI, which revealed 73% had disc abnormalities in the thoracic spine – 37% specifically had a thoracic herniated disc & 29% had spinal cord impingement. On follow up 26 months later none had developed thoracic back pain from their thoracic disc disorders.

Study shows that people may have upper back pain & a thoracic herniated disc, but the disc disorder may not be the cause of the thoracic back pain – it may be an incidental finding.

*Wood KB, Garvey TA, Gundry C, Heithoff KB. Magnetic resonance imaging of the thoracic spine. J Bone Joint Surgical Am. 77 : 1631-1638, 1995.

Scheuermanns Kyphosis

 A form of juvenile osteochondrosis most commonly affecting the thoracic spine.

 Higher incidence in males, & appears in adolescents, usually towards the end of their growth spurt.

 Growth abnormality of vertebral body causes the anterior endplate to grow slower than posteriorly  wedge shaped vertebra  kyphosis.

 Kyphosis is rigid & apex is usually T7-9.

 Normal curvature of Tsp is 20-50 wedging of 5   . A curvature of >50 or more = Scheuermanns.

 where spine has 3 contiguous vertebral bodies that have

Scheuermanns Kyphosis Presentation

 Increased A/P curves Lsp lordosis.

 Tsp kyphosis & compensatory   Often no pain from Scheuermanns, but more likely to have discomfort or pain with deformity as they age.

 Notorious for causing Lsp & Csp pain, & pain at apex of kyphosis if severe.

 Males often have broad, barrel chests.

 It has been reported that curves in the lower thoracic region cause more pain, whereas curves in the upper region present a more visual deformity.

Examination

 Examine the individual not the diagnosed condition!

 Postural roundback can be distinguished from Scheuermanns kyphosis by the fact the deformity disappears when the patient lies down.

 Often tight hamstrings due to increased lordosis in Lsp.

 Stand against a wall to examine anterior rib mobility so patient can’t employ the Lsp to assist.

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Is it the thoracic pathology causing the pain or is it a simple mechanical problem?

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Is their ‘label’ justified as a cause of their pain?

Treatment Strategy

 Work within the limits/parameters of the disorder, with patient cooperation.

 Treat mechanical issues as individually presented.

 Key areas to treat: Csp & T/L junction [often find new junctional areas – often at T6/7].

 Dependant on how heavily kyphosed & tailored according to maintaining factors – occupation, etc.

 If the patient is heavily loaded anteriorly, try to balance in supine position with pillow under Tsp.

Treatment Considerations

 With Scheuermanns, need to use long levers.

 Address segmental restrictions & local muscles as well as the large muscles spanning the spine.

 Stretch anteriorly.

 Work with ribs anteriorly & posteriorly, as well as working with key muscles iliocostalis & QL.

 Articulate & mobilise scapulo-thoracic joints.

 Often get a pseudo-SIJ problem – don’t symptom chase.

Case Presentation

Pt: Presentation: PMH: Osteopathic Evaluation: TTT given: Pre TTT NDI: Post TTT NDI:

F, 63yrs Painful Tsp & Csp with retracted and painful trapezius muscle post 2nd surgery. Left with exposed spinous processes over upper Tsp .

5yrs previously - T5 discectomy for disc protrusion with cord compression.

1yr previously - T4-6 posterior fusion with ligation of T4 nerve root.

Restricted flexion and extension C2 – T1. Hypertonic trapezius, levator scapulae, scalenes and SCM bilaterally.

Mobilise Csp & Tsp and address soft tissue component.

58% 32% Significant reduction in disability, reduction of medication and increase in daily activity.