This topic contains 10 replies, has 3 voices, and was last updated by 
Brandon Cohen DC, CSCS May 13, 2019 at 3:53 pm.
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Brandon Cohen DC, CSCS
What is a typical presentation of a thoracic disc?
I’ve had a couple of cases recently, where I have suspected this might be the case, but I’ve had trouble deciding between thoracic intercostal and rotation stuff or cervical disc. I also understand that there’s no reason you can’t have multiple things going on at any given time.
What is a typical location of pain where you wouldn’t consider cervical spine? Below the inferior angle of the scapula? Does thoracic disc refer more inferior and lateral? This would seem to make sense based on my understanding of cervical and lumbar disc referrals, but any online resources I have found show significant overlap with the cervical spine, and overlap for several thoracic levels. Most images I found reference to the z-joints and not the discs.
It seems that limited thoracic motion should be considered with thoracic disc, but in the cases I’ve seen a couple had significant limitation in the cervical spine as well as the thoracic, and because the cervical range is more detailed, easier to measure, and (in my opinion) more reliable, I tend to value that more…which I shouldn’t.
Long question longer, how do I rule in/out a thoracic disc in a patient who has pain in the middle to lower thoracic spine, provocatives in thoracic motions, limited range in cervical and thoracic spine? Ages are 24, 38, 50, both male and female. I know specifics are helpful, but really I’m looking for a general rule.
Thanks for all the help!
William Brady, DC
Good question. “How do I rule in/out a thoracic disc in a patient who has pain in the middle to lower thoracic spine, provocatives in thoracic motions, limited range in cervical and thoracic spine?”
You use the seven first order history elements. You can’t play the game with two or three. You provided symptom location: thoracic sclerotome / Provocative: thoracic loading and motion / Ages: all adult
Then you went into exam finding of limited ranges.
We need the data on a specific patient to get to the right details.
Lastly, just to jump ahead (as we all enjoy doing) keep in mind unlike cervical and lumbar; thoracic spine sclerotomes are more likely to be an end plate problem than a conventional disc problem. This additional pathology understand should help make sense of the presentation.
Brandon Cohen DC, CSCS
But Dr. Brady, I want blanket rules I can apply all the time irrespective of individuals and their specific needs.
…..I’ll write up a specific case.
William Brady, DC
These stupid “details” keep getting in the way! For some wonderful perspective you may enjoy this video from our friends at Rock Tape-
Now that’s how to make it easy*
*provided you are not interested in understanding, solving a problem or providing value.
Brandon Cohen DC, CSCS
Age: 25
Sex: male
Location: left lower thoracic spine, 1″ inferior to inferior angle, medial to inferior angle, (also, L. upper and posterior cervical spine, and left shoulder)
Quality: sharp with activity, achy at rest.
Intensity: 3-7/10
Provocative: B. Thoracic rotation, deep breathing, reaching overhead, thrusters, sleeping on L. side, sidestroke feels weak after 10 minutes.
Palliative: avoidance of aggravating factorsSecond order:
started 2 years ago, worse in the morning, works as a barista while training for Navy Seals, has decreased load over the past 4 months. Multiple providers and conservative treatments, no dx, no imaging.Post history dx: Thoracic disc, cervical disc?, adhesion
There are other points in the history that have me considering the shoulder a little, so we did a scan during the exam:EXAM:
Thoracic Flexion: flat 2.75″ at T7 with CC location discomfort.
TR: 35 degrees right with discomfort in area of CC. 40 degrees left with discomfort in area of CC.UCF: 76% with mild upper cervical spine tightness
CF: 76% with mild L. lower cervical spine pain.
CTF: 68% with mild pain in the L. lower cervical spine, and left interscapular area.
RCR: 75% with no sx
LCR: 90% with mild L. upper cervical spine tightness.SA: 90% with tension in the left mild tightness generally in the shoulder.
Push ups: 8, no symptoms or pain.
SLPF: fingers to the floor with bilateral posterior thigh stretch.Adhesions:
Thoracic interspinous ligament (3)
L. Thoracic erectors (3)
B. intercostals (2R, 3L)
B. Accessory nerve (2R, 3L)
L. Inferior GH capsule (3)
L. Lat Dorsi (2)There are other mild-moderate adhesions throughout the cervical, thoracic spine, and shoulder.
Post-exam dx: Adhesion, cervical disc
We have done 4 treatments. Started with Thoracic rotation (currently 50 degrees B with mild tension in the CC when performed to the right), then onto TF (currently flat for .5″ at T6), and that’s where we are. Ranges are maintaining, and symptoms are 30% better. Overhead work continues to be problematic, and sidestroke is weak after 15 minutes.
Most provocative thing has been identified as dumbbell shoulder presses. Pain is worse in the area of CC (L. lower thoracic spine) when pressing with the right shoulder. Pressing with the left shoulder is mild on the L.
We are making progress, but it feels like something is missing. I’ll probably start on the neck next time provided that thoracic rotation and flexion have maintained.
My questions are mostly diagnostic. What could cause that fatigue other than adhesion? What about the overhead pressing limitation. It kind of sounds cervical disc, but with the exam, I couldn’t reproduce sx with his ranges, but there is clearly limitation there.
Carl Nottoli, DC
Take a picture of the pain diagram from your history sheet. Look at the locations and see if they have any sclerotome patterns that fit.
Great work so far and there seems to be many layers to this case.
Brandon Cohen DC, CSCS
Thanks, Dr. Nottoli.
I’ve tried, but nothing really fits as far as cervical sclerotomes The closest would be C6-7, but that still seems an inch or two too superior. The maps for the thoracic spine have so much overlap from the pictures I’ve seen, I could call it anywhere from T5-T9.
I understand that thoracic disc issues are rare, and we are more likely to get endplate changes. Would those endplate changes also manifest in the same patterns?
Also, I’m connecting the pain with the right shoulder press with stabilization of the thoracic spine, or is it compression to the cervical spine? I keep coming up with more questions as I look for answers…
William Brady, DC
Brandon, this sounds like a rare presentation, but great case for following the ID system. Let’s set up a 30 minute coaching call and we can review this case. Instead of charging you I will post it here. Sound good?
Brandon Cohen DC, CSCS
Sounds great.
William Brady, DC
We had a great coaching call the end of March regarding this thread. You can watch in the coaching sessions section. Thanks
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