853-T spine pathos

PT diagnosis for TOS

depends on movement pattern

TOS

refers to compression of neurovascular strcutures in the interscalene triangle

interscalene triangle 

• anterior: anterior scalene

• posterior: middle scalene

• inferior: medial surface of 1st rib

• brachial plexus trunk and subclavian artery pass through

costoclavicular space

• anterior: middle third of clavicle 

• posteromedial: by the first rib

• posterolateral: upper border of scap

thoraco coraco pectoral space

• superior: coracoid process

• anterior: pec minor

• posterior: ribs 2, 3, 4

• brachial plexus continues through this space alongside the subclavian artery

bony abnormalities that could impact the thoracic outlet

• cervical rib

• elongated C7 transverse process

• abnormalities of the 1st rub or clavicle

soft tissue abnormalities that could impact the thoracic outlet 

• congenital abnormality of the scalene muscles 

• hypertrophy of the anterior scalene 

• brachial plexus passing through the anterior scalene muscle 

joint impairments that could impact the thoracic outlet

• clavicle needs to be able to elevate, retract, and spin posteriorly during arm elevation

• AC joint needs to allow scapular movement 

symptoms of true nTOS

• typically “compressor” symptoms, day>night

• objecitve weakness and/or sensory loss

• confirmed with positive neurophysiological testing

symptoms of disputed nTOS

• “releasor” symptoms, night>day

• subjective weakness and/or sensory changes

• neurophysiological tests are normal

nature of symptoms with TOS

varies with upper or lower brachial plexus involvement 

aggs for TOS

overhead work, prolonged sitting with forward head posture, and increased thoracic kyphosis

24 hr pattern for TOS

may awaken at night due to UE paresthesias

release phenomenon 

• release of tension and/or compression of the perineurial blood supply to the brachial plexus

• signals return of normal sensation

• prognostic indicator of favorable outcome 

TOS “releasors”

those with symptoms at night due to release phenomenon

TOS “compressors”

pts with symptoms during the day associated with compression on the thoracic outlet from aggs

posture for TOS

• rounded shoulders, forward head, increased thoracic kyphosis

• also posterior tilt, downward rotation, and/or depression of the scaps 

integ screen for TOS

• cyanosis with vTOS

• paleness with aTOS

positive cervical rotation lateral flexion tests in TOS patients

• suggests elevated 1st rib

• cervical side bendind is limited due to TP of T1 contacting and being blocked by elevated 1st rib

special tests for nTOS

• supraclavicular pressure test

• adson’s test

• costoclavicular manuever

• wright’s test

• cyriax release test

• roos test

potential pertinent history for TOS

• may not report any meaningful history

• may report more symptomatic with overhead activities 

potential predisposing factors for TOS

bony abnormalities in the C or upper T spine and/or 1st rib

diagnosis of TOS is supported when

• history includes non-radicular symptoms in the neck, shoulder,arm which are worsened by movements and/or position of the neck, arms, and shoulder girdle

• accompanied by cluster of provocation tests

• assessment of postural dysfucntions and “container” mobility indicates tension and/or compression on the brachial plexus

medical management for TOS

radiographs may be used to rule out a cervical rib, long TP of C7, or sequelae of prior clavicle fracture

• C spine radiographs: rule out spondy or osteophytes 

• chest x-rays: rule out pancoast tumor

EMGS: may show abnormal results

conservative: botox injections to anterior and middle scalenes to temporarily reduce pain and spasm 

PT diagnosis for T4 syndrome

usually a pattern of painful thoracic flexion

definition of T4 syndrome

clinical pattern that involves UE paresthesia and pain w/ or w/o symptoms into the neck and/or head

pathobiological mechanisms of T4 syndrome

• hypothesized that segmental spinal nerves that contain afferent fibers from sympathetic nerves are entrapped, or sympathetic fibers are experiencing ischemia

• hypothesized that sustained or extreme postures tax the arteriolar system of the SNS, causing microtrauma

S+S of T4 syndrome 

• paresthesia in all 5 fingers, in whole hand, or in forearm + hand

  • UL or BL

  • non dermatomal pattern

• hands feel hot or cold, arm may feel heavy

• hands feel or might be swollen

• aches and pains, non dermatomal pattern

• combo of neck, upper T and cranial pain w/ or w/o abnormal neuro signs 

• headaches that present in cap presentation

nature of symptoms for T4 syndrome

pains may be crushing, bursting, or like a tight band 

aggs for T4 syndrome

pt dependent but often related to poor posture

eases for T4 syndrome

hot shower

massage/ mobilization

24 hr pattern for T4 syndrome

• can start in AM and worsen with activity throughout the day

• can be worse at night and affect sleep

objective exam for T4 syndrome

• PA accessory mobs at T4 segment reproduces the pt’s symptoms

• palpation of rib angles may elicit symptoms

• observation of trophic changes in the UEs

• positive neural provocation tests of the upper limbs

potential pertinent history for T4 syndrome

often insidious onset but may report:

• symptoms onset after start of new job

• change of work practice

• starting a new hobby

• jobs with bending and forward stooping, or sedentary posture

potential predisposing factors for T4 syndrome

sedentary lifestyle and impaired posture

PT management for T4 syndrome

• manual therapy directed to T spine

• postural edu and re-training

• movement reeducation after successful manual therapy interventions

medical management for T4 syndrome

• radiograph and EMG studies typically negative

• NSAIDs may assist with symptom management

PT diagnosis for thoracic disc pathology 

typically a pattern of thoracic flexion

S+S of thoracic disc pathology

• may be asymptomatic

• when symptomatic, symptoms are often non specific intermittent back pain

• may or may not have sensory and/or motor changes

symptom nature for thoracic disc pathology

non specific pain and stiffness

aggs for thoracic disc pathology

coughing, sitting, bearing down

eases for thoracic disc pathology

standing, lying supine

24 hr pattern for thoracic disc pathology-

• often stiffness first thing in the morning lasting for approx. 20 minutes

• may worsen throughout the day with sitting

objective exam for thoracic disc pathology

• impaired spinal ROM

• possible positive neural provocation tests

• may have neuro signs if disc is compromising a nerve root or the spinal cord

potential pertinent history for thoracic disc pathology

• most likely will report insidious onset

• could report traumatic event such as fall onto the buttocks

potential predisposing factors for thoracic disc pathology

• occupations or activities that require repetitive flexion

• increased thoracic kyphosis

PT management for thoracic disc pathology

initial: decrease symptoms and promote healing

• encourage active rest: walking

• avoid lifting/carrying as able

then, work on improving mobility and movement patterns

• emphasize thoracic extension and stabilization exercise

• address psotural impairments

medical management for thoracic disc pathology

imaging

• radiographs may show spurring or failure at vertebral endplates

• MRIs still gold standard

surgery

• not common but options are laminectomy or costotransversectomy

PT diagnosis for throacic facet dysfunction

will depend on problematic movement pattern

throacic facet dysfunction

• symptoms typically UL and may report stiffness

• can result from hypo or hyper mobility of facet

• pain with palpation of involved facet

• PT management should focus on joint mobility and adressing relavent movement impairments

Indications for surgery for neurogenic TOS

For those with true neurological symptoms

• weakness

• Wasting of hand intrinsic muscles

• Nerve conduction study less than 60m/second

Surgical options for neurogenic TOS

Technique should address the underlying cause of TOS

• 1st rib resection

• Cervical rib resection

• Anterior and middle scalenectomy

• Remove fibrous bands

• Remove callus

Indications for surgery for venous TOS

S+S of venous thrombosis

Surgical options for venous TOS

Thrombolytic therapy to dissolve acute thrombus

• best if given within 1 week of symptom onset

• Still effective up to 1 month post onset

Indications for surgery for arterial TOS

Potential for upper limb ischemia

Surgical options for arterial TOS

• arterial reconstruction

• Thrombolytic therapy or balloon thrombolectomy

• Distal bypass grafting