Thoracic Radiculopathy

Definition/Description

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Thoracic radiculopathy refers to a compressed nerve root in the thoracic area of the spine. This is the least common location for radiculopathy. The symptoms often follow a dermatomal distribution, and can cause pain and numbness that wraps around to the front of your body..

  • The pinched nerve can occur at different areas along the thoracic spine
  • Symptoms of radiculopathy vary by location but frequently include pain, weakness, numbness and tingling.
  • A common cause of radiculopathy is narrowing of the space where nerve roots exit the spine, which can be a result of stenosis, bone spurs, disc herniation or other conditions.
  • Radiculopathy symptoms can often be managed with nonsurgical treatments, but minimally invasive surgery can also help some patients.

The most important structures which are involved with a thoracic radiculopathy are the:

  • Thoracic vertebrae (T1-T12)
  • Intervertebral disc of the thoracic vertebrae,
  • 12 pairs of spinal nerve roots,
  • 12 rami - posterior rami innervate the regional muscles of the back, ventral rami innervate the skin and muscles of the chest and abdominal area.[1]

Epidemiology /Etiology

Unknown, the diagnosis of thoracic radiculopathy is overlooked. 

Thoracic radiculopathy has been infrequently reported and described as uncommon.

Radiculopathy typically is a mechanical root compression , most commonly caused by:

  • Diabetes mellitus - 15% insulin-dependent and 13% non-insulin-dependent have diabetic thoracic polyradiculopathy.[2]
  • Degenerative spine changes such as disc herniation and spondylosis.

Other possible causes of mechanical root compression are a metastatic tumor, trauma, scoliosis, viral infection/inflammation, connective tissue disease and tuberculosis.

Characteristics/Clinical Presentation

  • A person may experience pain in the chest and torso when the nerve compression or irritation occurs in the mid back region.
  • Thoracic radiculopathy is an uncommon condition that may be misdiagnosed as shingles, heart, abdominal, or gallbladder complications.

Symptoms associated with thoracic radiculopathy include:

  • Burning or shooting pain in the rib, side, or abdomennumbness and tingling
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The symptoms of thoracic radiculopathy, regardless of the cause, are often not recognized, as there is typically no associated motor deficit.

  • When the etiology is disc herniation or trauma, motor deficit or myelopathy may be observed in the advanced stages.
  • The typical presentation of band-like thoracic or abdominal pain can mimic a myriad of conditions .
  • With many differential diagnoses to consider, it is not surprising that thoracic radiculopathy is often not discovered for months, or years, after symptoms arise[3]

Diagnosis

In addition to a physical exam and symptom review, doctors may diagnose radiculopathy using:

  • radiologic imaging with X-ray, MRI, and CT scans
  • electrical impulse testing called electromyography or EMG, to test nerve function
  • The exclusion of other causes of pain is the most important step in the diagnostic procedure as there are a lot of generators of thoracic pain and differentiating these differential diagnoses will be difficult[1]

Differential Diagnosis

  • Postherpetic neuralgia
  • Chronic abdominal wall pain
  • Malignancy
  • Other spinal disorders (e.g. spinal cord tumors, compression by intervertebral discs)[4]
  • Spinal: Infectious, neoplastic (primary, metastatic), degenerative (spondylosis, spinal stenosis, facet syndrome, disc disease/HNP), metabolic (osteoporosis, osteomalacia), deformity (kyphosis, scoliosis, compression fracture, somatic dysfunction), neurogenic (radiculopathy, Herpes Zoster, anteriovenous malformation)
  • Extraspinal: Intrathoracic (cardiovascular, pulmonary, mediastinal), Intra abdominal (Hepatobiliary, gastrointestinal, retroperitoneal), Musculoskeletal (Post-thoracotomy syndrome, polymyalgia rheumatica, myofascial pain syndrome, somatic dysfunction, rib fractures, costochondritis), Neurogenic (Intercostal neuralgia, peripheral polyneuropathy, RSD/CRPS)

Outcome Measures

VAS

Oswestry Disability Index.[2]

Examination

Includes

  • Symptoms (already discussed earlier).[5]
  • Due to non-universal tenderness and the sensory changes, it is not reliable to do a sensory examination.
  • Physical examination is not the best way to evaluate thoracic radiculopathy, unlike the lumbosacral and cervical radiculopathies the affected muscles cannot be tested isolated.
  • The examination will rather be used to exclude other diagnoses then to determine a thoracic radiculopathy.[1]

Thus the examination will be done with more medical strategies and therefore we can use: EMG, MRI, CT, radiographs

Medical Management

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Physical Therapy Management

Physical modalities of the therapy include:

  • heat,
  • ultrasound
  • TENS.
  • Spinal extension exercises..[1]
  • Rest Education: avoid the activities that produce the pain (bending, lifting, twisting, turning, bending backwards, etc).
  • Apply ice in acute cases to the thoracic spine to help reduce pain and associated muscle spasm.
  • An exercise regiment designed specifically to address the cause of the symptoms associated with pinched nerve and improve joint mobility, spinal alignment, posture, and range of motion.
  • Restore joint function ( eg Spinal manipulations or mobilisations[6])
  • Improve motion
  • Help the return of full function.

Clinical Bottom Line

Mild Cases

  • In mild cases many patients found that rest, ice and medication were enough to reduce the pain. Physical therapy is recommended to develop a series of postural, stretching and strengthening exercises to prevent re-occurrence of the injury. Return to activity should be gradual to prevent a return of symptoms.

Moderate to Severe Cases

  • If the problem consultation with your health care provider. Your physician should perform a thorough evaluation to determine the possible cause of your symptoms, the structures involved, the severity of the condition, and the best course of treatment.[7]

References

  1. 1.0 1.1 1.2 1.3 Thoracic radiculopathy, Ryan C. O’Connor et al., Physical & Medical Rehabilitation Clinics of North America, 2002 (evidence level 3B)
  2. 2.0 2.1 Non-Surgical Interventional Treatment of Cervical and Thoracic Radiculopathies, Pain Physician, Richard Derby, Yung Chen, Sang-Heon Lee, Kwan Sik Seo, and Byung-Jo Kim, Pain Physician, 2004 (evidence level 1A)
  3. Choi HE, Shin MH, Jo GY, Kim JY. Thoracic radiculopathy due to rare causes. Annals of rehabilitation medicine. 2016 Jun;40(3):534. Available from:https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4951374/ (last accessed 25.4.2020)
  4. The Clinical Anatomy and Management of Thoracic Spine Pain, L.G.F. Giles, 2000 (table 18.1 elements of the physical examination p 288) (evidence level 5)
  5. Surgical Treatment of T1-2 Disc Herniation with T1 Radiculopathy: A Case Report with Review of the Literature, T1-2 Disc Herniation / 199, Eun-Seok Son et al., Asian Spine Journal, 2012 (evidence level 3A)
  6. T2 radiculopathy: A differential screen for upper extremity radicular pain. Sebastian D., Physiotherapy Theory and Practice, 2013 (evidence level 3B)
  7. Redefine HC Thoracic radiculopathy Available from:https://redefinehealthcare.com/thoracic-radiculopathy/ (last accessed 25.4.2020)
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