Thoracic Spine Syndromes

Alexandros Sideris
PT, MSc, OMT, Dip.Acu
Terminology

•Pseudovisceral syndromes
•Pseudoangina
•Τ4 Syndrome
•Τ10 Syndrome
Disorders of the thoracic spine are often
accompanied by symptoms originating
from the autonomic nervous system.
(McGuckin, Fraser 1989, Maitland 2001)
Spondylosis or degenerative changes of the costovertebral
joint can cause a mechanical stimulation of the
sympathetic chain, which leads to sympathetic-related
symptoms to the arm(s).
(Evans 1997)
Autonomic Nervous System

Diabetes. 2003;52(11)
© 2003 American Diabetes Association
 Thoracic Vertebrae Syndromes
Differentiation of visceral to somatic pain is that visceral is being
modulated by the autonomic nervous system, as the stimulus travels
inside the CNS to the brain.

Elie O. AI-Chaer, * Yi Feng, and William O. Willis, Pain, 1998

 Thoracic Vertebrae Syndromes

• One pregangliotic neuron, is being connected with multiple

metagangliotic neurons on the sympathetic chain, and interacts with
somatic neurons that innervate a large variety of tissue targets.
• The head, and the neck region are sympathetically innervated by Τ1 –
Τ4
• Upper trunk and upper limb byΤ1 – Τ9.
(Bogduk,2002 )

• So it is possible that dysfunction of the sympathetic system on T4, to

lead to referred on the head, the upper trunk and the arm.
Thoracic Vertebrae Syndromes
Thoracic Vertebrae Syndromes
 Somatic afferent / efferent fibers Sympathetic ganglion

Dorsal ganglion

Dorsal root

Ventral root

Sympathetic afferent / efferent

Vasomotor nerve fibers descend in the spinal cord and
emerge in the ventral horns and roots. These fibers pass the
dorsal root ganglia as it sits in the intervertebral foramen.
Next they emerge as part of a spinal segmental nerve.
Sympathetic fibers leave the segmental nerve and join the
sympathetic chain. Then it travels down the neck of the ribs
with variable areas of the ganglia.
Evans 1997
Branches from the sympathetic chain pass over the costovertebral joints to supply
the heart, esophagus, and abdominal viscera.It is not uncommon for these
branches to become stretched or affected by neighboring osteophytes.

The sympathetic chain fibers ascend or descend a variable number of segments

synapse in a ganglion, and leave the chain to join a peripheral nerve.

Sympathetic fibers can pass distally leaving the peripheral nerve to join an artery
in the neurovascular bundle. Here they assist with the control of blood pressure
via vasoconstriction.
Evans 1997
Thoracic Vertebrae Syndromes

• Checking on active as well as passive mobility of the thorax is

essential when trying to control pain or vascularization on
CRPS patients.

Menck JY, Requejo SM, Kulig K. J Orthop Sports Phys Ther, 2000;30(7):401-
9.

• The effectiveness of mobilizations on regulating the

autonomic nervous system (mostly sympathetic), has been
proved on few but interesting studies

Wright, Manual Therapy 1995

Perry and Green, Manual Therapy 2008
Jowsey and Perry, Manual Therapy 2010
Τ4 syndrome - Hypothesis
 Τ4 syndrome
Clinical presentation

paraesthesias to the upper limbs and hands, all five digits

hand and forearm numbness
upper extremity coldness
Hands feel hot or cold
hand clumsiness
heaviness in upper extremities
hands feel and may objectively be swollen
Conroy, Schneiders, Manual Therapy, 2004
upper extremity pains
associated with or without
headaches and upper back
stiffness

intermittent posterior pain

or pain around the scapula

referred pain

pain often described as

crushing or like a tight band

Conroy, Schneiders, Manual

Therapy, 2004
Pain and stiffness ->around chest
wall with pain anterior and posterior

interscapular pain or stiffness

worse pain at night

The pain can become sharp and

stabbing and increased with quick
trunk or upper-extremity
movements, deep breathing,
coughing or sneezing, and changing
positions in bed
 Clinical Examination Τ4
• Without neurological signs
• Increased muscle tone (esp trapezoid)
• Upper rib stiff and painful
• Upper cross syndrome – lordosis for upper T-spine – kyphosis for mid
and lower T-spine
• Hypomobile Τ2-Τ6 + ribs
• Mobility testing for C-Spine and scapular kinesis

• Causes of T4 are still today not clear, but it is correlated with T-spine
hypomobility

Fruth S. Differential Diagnosis and Treatment in a Patient with

Posterior Upper Thoracic Pain. Physical Therapy. 2006
T4 Syndrome Treatment Options

Postural education
Functional exercise
ROM exercises
Motor control
Manual Therapy - Joint Mobilization
TrP release
• RCT
• Grade III PA on Τ4 rotatory mobilization
technique
• Frequency 0.5 Hz
• Caused increase in sympathetic vasomotor
reflex which was statistically significant
compared to placebo group

Jowsey & Perry, Manual Therapy 2010

Highlights

 Bylateral mobilization of upper T- spine causes significant bilateral vasodilation

 Vasodilation effect stayed for a prolonged period of time, if mobs where of high
pressure and load

 These results could be explained by mechanisms dependent on pressure and

load
 Τ10 Syndrome
Case report - Bilateral leg symptoms - The T10 syndrome?
Wouter Kristiaan Geerse*, Manual Therapy 2012

Referred pain to both legs

No neurological signs
No dermatome sensitivity
Neural tissue hypo mobile
T10 with high load and structural stress to the intervertebral disk

Treatment consisted of mobilization grade III, in 4 sessions, significant

decrease of symptoms
https://www.physio-pedia.com/T4_Syndrome