Transcript 12. Thoracic disc disease and Scheuermanns

September 5th – 8th 2013
Nottingham Conference Centre, United Kingdom
www.nspine.co.uk
Thoracic Disc Disease
 Most common location is at T/L junction & T8-12.
 Herniated disc
Upper back pain, radiating pain & numbness.
 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  sensory disturbances
e.g. numbness, below level of compression, difficulty
with balance & walking, lower extremity weakness, or
bowel or bladder dysfunction.
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. A curvature of >50
where spine has 3 contiguous vertebral bodies that have
wedging of 5 or more = Scheuermanns.
Scheuermanns Kyphosis Presentation
 Increased A/P curves -  Tsp kyphosis & compensatory 
Lsp lordosis.
 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.
 Is it the thoracic pathology causing the pain or is it a
simple mechanical problem?
 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:
F, 63yrs
Presentation:
Painful Tsp & Csp with retracted and painful trapezius
muscle post 2nd surgery. Left with exposed spinous
processes over upper Tsp .
PMH:
5yrs previously - T5 discectomy for disc protrusion
with cord compression.
1yr previously - T4-6 posterior fusion with ligation of
T4 nerve root.
Osteopathic
Evaluation:
Restricted flexion and extension C2 – T1. Hypertonic
trapezius, levator scapulae, scalenes and SCM
bilaterally.
TTT given:
Mobilise Csp & Tsp and address soft tissue
component.
Pre TTT NDI:
58%
Post TTT NDI:
32%
Significant reduction in disability, reduction of
medication and increase in daily activity.