T4 Syndrome

Original Editor - Ernest Gamble

Top Contributors - Abbey Wright, Ernest Gamble, Admin, Rachael Lowe, Liena Lamonte, Stijn Van de Vondel, Evan Thomas, Oyemi Sillo, Kim Jackson, Yahya Al-Razi, Ilona Malkauskaite and Lucinda hampton

Clinically Relevant Anatomy

A typical thoracic vertebra has a total of six joints with neighboring vertebrae: four synovial joints and two symphyses.
Although the movement between any two vertebrae is limited, the summation of movement among all vertebrae results in a large range of movement by the vertebral column. [6; LOE 5]

There are two major types of joints between the vertebrae [6; LOE 5]:
- Symphyses between vertebral bodies
- Synovial joints between articular processes

The synovial joint between superior and inferior articular processes on neighboring vertebrae are the zygapophysial joints. A Thin articular capsule attached to the margins of the articular facets covers each joint. In thoracic regions , the joints are oriented vertically and limit flexion and extension, but facilitate rotation [6; LOE 5].

In 1997 Evans described the basic science behind the origins of T4 syndrome[1; LOE 5]. Vasomotor nerve fibers descend in the spinal cord and emerge in the ventral horns and roots. These fibers pass the dorsal root ganglia as it sits in the intervertebral foramen. Next they emerge as part of a spinal segmental nerve.
Sympathetic fibers leave the segmental nerve and join the sympathetic chain. Then it travels down the neck of the ribs with variable areas of the ganglia. Branches from the sympathetic chain pass over the costovertebral joints to supply the heart, esophagus, and abdominal viscera.It is not uncommon for these branches to become stretched or affected by neighboring osteophytes.
The sympathetic chain fibers ascend or descend a variable number of segments synapse in a ganglion, and leave the chain to join a peripheral nerve.

Sympathetic fibers can pass distally leaving the peripheral nerve to join an artery in the neurovascular bundle. Here they assist with the control of blood pressure via vasoconstriction.  It is thought that the head and neck are provided with sympathetic outflow from T1 to T4. The upper trunk and extremities are thought to be supplied by T2 to T5. Symptoms in the neck, head, and upper extremities are common. 

Mechanism of Injury / Pathological Process

The exact mechanism of T4 syndrome is unclear but it is hypothesized that sustained or extreme postures can lead to relative ischemia within multiple tissues contributing to symptoms of sympathetic origin. Symptoms originating from the sympathetic nervous system are distinctly different from somatic referred symptoms. The sympathetic nervous system provides pathways for referral of symptoms from the thoracic spine to the head and upper extremities. Symptoms may not be derived solely from the fourth thoracic vertebra, but also other upper thoracic vertebra. Hence “T4 syndrome” may also be referred to as “upper thoracic syndrome”.

Clinical Presentation

Patients presenting with T4 syndrome are typically between 30 to 50 years of age. The condition occurs more frequently in women by a 4:1 ratio. Symptom onset may coincide with a new job or hobby, especially those that require frequent stooping or bending (electricians, surgeons, and assembly-line worker’s). Frequent posturing in front of computer has also been implicated. Symptoms are often diffuse and located in the neck, head, and upper extremities (unilateral or bilateral)

.

Upper extremity paraesthesia and pain with or without neck and/or head pain:

• Paraesthesias in all five digits, or whole hand, or forearm-hand (glove-like distribution)
• Hands feel hot or cold
• Heaviness in upper extremities
• Hands feel and may objectively be swollen
• Non-dermatomal aches/pains in arm and/or forearm
• Pain often described as crushing or like a tight band

Less common symptoms could include

• Pain and/or stiffness radiating around chest wall
• Interscapular pain and/or stiffness
• Worse pain at night often waking from sleep
• Creepy-crawly feelings or sensations of gushing water in arm
• Normal UE sensory, motor, reflex testing

Objective signs commonly include:

• Upper thoracic segmental mobility assessment commonly hypomobile and may reproduce or eliminate symptoms
• Palpation of rib angles may elicit distal symptoms
• Positive neural tension signs in the involved upper extremities
• Forward head posture and/or possible flat thoracic spine
• Cervical and trunk AROM may be pain free
• Hands may appear discolored (red or purple) and feel hot or cold to touch
  

Diagnostic Procedures

There are no validated clinical criteria to assist in diagnosing T4 syndrome. Also, radiographs do not aid in the diagnosis, however they may help rule out other condition.

Outcome Measures

No self-report outcome measure has been validated for this specific condition. Any number of outcome measures would be appropriate for this patient population. This includes the Patient Specific Functional Scale (PSFS), Neck Disability Index (NDI), and Quick DASH

Management / Interventions

• Thoracic spine and rib cage (costovertebral and costotransverse joints) mobilization/manipulation
• Cervical spine mobilization/manipulation
• Soft tissue mobilization to hypertonic musculature in cervicothoracic region
• Self-mobilization techniques to the upper thoracic spine
• Postural exercise and education
• Strengthening of the scapulothoracic musculature
• Stretching tight pectoral and other upper quarter musculature
  

Differential Diagnosis

Symptoms of T4 Syndrome can be confused with carpal tunnel syndrome, myofacial pain syndromes, cervical spine degenerative conditions, thoracic outlet syndrome, cardiac pain and pain originating from the viscera. Signs and symptoms of cardiac pain include the following

• Early mild symptoms include pain in region of the left breast/sternum; and tingling down the left arm into the hand.
• Feelings of a crushing tight band around the chest wall
• Pain radiating down the left arm (uncommonly the right), up the left side of the neck, into the throat and possibly to left half of the tongue.
• Symptoms worsen with exertion (especially in cold weather) and ease with rest.

Key Evidence

Several case studies have been reported in the literature. No validated diagnostic criteria have been established for T4 Syndrome. No randomized controlled trials have examined the most efficacious intervention strategies.

Recent Related Research (from Pubmed)

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