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

September 5 th – 8 th 2013 Nottingham Conference Centre, United Kingdom www.nspine.co.uk. Osteopathic Management of patients with Thoracic Disc Disease and Scheuermanns Kyphosis. Thoracic Disc Disease. Most common location is at T/L junction & T8-12. Herniated disc

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

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

  2. Osteopathic Management of patients with Thoracic Disc Disease and Scheuermanns Kyphosis

  3. 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.

  4. 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.

  5. 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.

  6. 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.

  7. 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.

  8. 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.

  9. 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?

  10. 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.

  11. 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.

  12. Case Presentation

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