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Symptom-complex of a Typical Patient with T4 Syndrome

Age range: Usually 35 years upwards Body type: Poking chin, possibly with angulation at cervico-thoracicjunction (kyphosis); thoracic spine may be flattened Job type: May demand much forward stooping or bending - electricians,surgeons, seated factory assembly line work - on the line Previous investigations: Thoracic outlet, cardiac, gut problems Onset: Often follows start of new job or change o f working practice or taking up new hobby, etc Symptoms usually present, may be unilateral or bilateral: 0 Paraesthesiae in all five hand digits, or in the whole hand, or in the forearm and hand, ie glove-type (long/short) 0 Hand feels hot or cold, may objectively be so 0 Arm may feel heavy 0 Hand feels swollen, may actually be so 0 Aches and pains, non-dermatomal,in arm and/or forearm 0 Pains may be crushing, bursting, or like a tight band Symptoms sometimes present:

The T4 Syndrome
Some Basic Science Aspects
Philip Evans
Key Words
Thoracic spine, pain, symptoms, sympathetic

Introduction
The T4 syndromc is a term used by clinicians for patients whose varied problems seem t o be derived from the upper thoracic spine, and may be helped by treatment and exercises directed at that region. Properly it should perhaps be called the upper thoracic syndrome, a s symptoms may not be derived just from the fourth thoracic vertebra (T4), b u t it is easier to use the shorter name. Although some of these symptoms occur in patients whose T4 is unaffected, and the syndrome itself is often overlaid or accompanied by other symptoms, experienced clinicians all carry in their mind a picture of the T4 syndrome, and will recognise it and name when they find it in a patient. Grieve (1981) in his magnificent and monumental work has written ten pages which apply to it, and Bogduk (1986) has written a brief note about it as a model for what a research paper should be like, as well as a useful chapter on pain derived from the thoracic spine. Bogduk (1988), Ebbetts (1971) and Caillet (1981) provide useful contributions on pain. McGukins (1986) chapter in Grieves other magnum opus is surely required reading for all clinicians dealing with patients who walk i n through the door unreferred and uninvestigated. But the syndrome retains a slightly mysterious aura, though it is not a n uncommon presentation in physiotherapy practice, and the writer has met it in a number of patients in a n accident and emergency department. While I was researching this puzzling syndrome, some interesting things came to light, which a r e worth communicating. This paper is written chiefly to present the syndrome from the aspect of clinical anatomy. Clinician readers are

Pain and stiffness radiating round chest wall, or small areas of pain anteriorly or posteriorly 0 lnterscapular ache or pain and stiffness 0 May be worse at night, stopping sleep or wakening from sleep 0 Creepy-crawly feelings over affected part (formication - ants creeping),or watery feelings, or a sensation o gushing water f 0 Neurobiomechanics: Tension tests are often positive, with typical symptoms 0 Cervical spine: Because of the position o the f neck, concomitant cervical spine symptoms
0

Objective Signs

Hands may discolour, appearing red or purple, and feel hot or cold 0 Bodily habitus, as above - poke and stoop
0

Findings

Symptoms not affected by active movement of spine 0 On palpation, stiff motion segments, palpation of which may elicit or ameliorate symptoms 0 Palpation of rib angles may elicit symptoms, especially distal tingling (Smith, 1991)
0

Helped by:

Mobilisations of upper thoracic spine, rib angles or lower cervical spine, ultrasound, or other physiotherapy 0 Home exercises, anti-neck-poking, stand up straight!,thoracic automobilisation, possible ergonomic options.
0

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asked to forgive any repetition of well-known facts, some of which are due t o the ignorance of the writer, while others are included for clarity.
Because in an accident and emergency department these patients are so often found in the resuscitation suite with electrocardiogram (ECG) leads attached, that it is evident the syndrome becomes confused with cardiac pain. Since also an apparent T4 syndrome may in fact be due t o cardiac pain, it could be prudent to summarise briefly the pointers that may lead a clinician t o suspect the heart as the source of symptoms.

As our population increasingly ages, this pain is a daily acquaintance of many of our patients.
Cardiac pain also has a pattern, a distribution that should be well known to the medical profession, and is shown on the body chart in figure 1. Pain in the epigastrium can be from the heart as well as from indigestion. And as with many syndromes, a patient may present with many of these symptoms and have cardiac pain; or only one of them, and still have cardiac pain. Thus a man who came t o casualty at 4 am with severe pain in the thenar eminence, who was sent for an X-ray of the thumb, later complained that it spread t o his arm and chest, when he was correctly diagnosed.

Cardiac Pain
It is the subjective history t h a t gives the real
indicators that a patients pain is cardiac. It is described as crushing, as a band tight round the chest, also as if the chest wants t o burst. The same pain may radiate down the left arm (uncommonly the right), up the left side of the neck, and into the throat and left half of tongue. Early or mild pains, or residual symptoms after infarction, can be felt over a small area which is pointed out with the finger tips over the left breast or on the sternum; tingling down the left arm into the hand is a well-known warning sign. But even above the symptomatology, in ischaemic heart pain (angina pectoris) the timing of the pain is crucial. It comes on with exercise, and improves or clears with rest. Exercise in cold weather or against adverse winds makes it worse; and especially if a heavy meal has just been eaten; walking the dog on Christmas Day can be hazardous!

So cardiac pain has its own pattern, equivalent to the dermatomes of several segmental spinal nerves. The cardiac pain pattern is overlapped by the pain pattern of other viscera, especially the oesophagus, which mimics the distribution almost exactly. Moreover, it is not only viscera that refer distally within the cardiac pattern, for there are many proximal sources of pain felt in the thenar eminence, for example the costo-clavicular and acromio-clavicular joints. Since the thenar eminence and the two joints do not share the same somatic innervation, some other factor, which also explains cardiac pain, must be involved.

Innervation of Viscera
Viscera have no somatic (conscious) innervation. Their innervation is autonomic, by para-sympathetic (secreto-motor usually) and sympathetic (vasomotor mostly) nerves. It is instructive to ask: What causes the pain felt from heart, gall bladder, and other viscera? What can be the end-organ that signals pain, and where exactly is it? The heart is made of heart muscle, which has no sensory nerve supply. One nerve supplying the heart is the vagus, which slows the heart by action on the pacemaker. These vagal fibres do not extend into heart muscle and are not sensory. The other nerve supply is uia the cardiac nerves, which descend to the cardiac plexus from the cervical sympathetic ganglia. They also supply the pacemaker, speeding up the rate, but they go on to supply the blood vessels of the heart. They do have sensory nerve fibres, which run with the sympathetic nerves on the arterioles, and they come from the nerve endings on the vessels. These sensory fibres are classed as visceral afferents; the sensation they carry is vague and non-specific, quite unlike that of common sensation, which is carried by somatic afferent fibres. So the structures signalling pain in angina pectoris are nerve endings on the arterioles inside the heart muscle.

Fig 1: Body chart of typical cardiac pain

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fibres then leave the nerve and join the sympathetic chain. These connections are easily seen at dissection - the sympathetic chain is an irregular line, branching and looping on the necks of the ribs with variable lumps or ganglia (the Greek word ganglion means lump)- see figure 3. Branches pass forward over the vertebral bodies o r costo-vertebral joints t o supply the heart, oesophagus and abdominal viscera. Here they may be stretched o r even buried in osteophytes (fig 3). Once in the sympathetic chain they ascend o r descend a variable number of segments (currently thought to be six to eight but increasing in the literature), synapse in a ganglion, and leave the chain to join a peripheral nerve. (All peripheral nerves, and not just the sinu-vertebral nerve, are mixed somatic and Sympathetic.) Clinician readers will have had their own experiences of the number of segments distant from their exit level at which symptoms have been produced. They pass distally and leave the peripheral nerve to join an artery in the neurovascular bundle. The sympathetic nerves form a vasoconstrictor network on all arterioles, right up t o the capillaries. They control blood pressure, and with the blood vessels go to every part of the body - there are very few places in the body without a blood supply. Sympathetic nerves are motor, but they do contain afferent (sensory) nerve filaments, which synapse in the dorsal root ganglion and enter the spinal column with the somatic afferent nerves. Properly, they are visceral afferent fibres.

Fig 2: Upper thoracic vertebra and rib. Sympathetic fibres are shown in magenta. See description in text

Sympathetic Outflow
At the risk of alienating those angels, geniuses and memory tanks who know the topography of the sympathetic outflow it is repeated here. From the hypothalamus the motor tracts descend in the spinal cord, leaving it at levels T1 to L1 approximately. The motor comprises vasomotor fibres which emerge in the ventral horns and ventral roots, passing the dorsal root ganglion as it sits in the intervertebral foramen, and emerge as part of a spinal segmental nerve (fig 2). The sympathetic

Of the sympathetic outflow, Grays Anatomy shows the head and neck being supplied by levels T1 to T4, and the upper trunk and upper limb by T2 to T5 (Williams et al, 1989). This fits well with the title upper thoracic syndrome.
The sinu-vertebral nerve, like most other peripheral nerves, is mixed somatic and sympathetic. While the dorsal (somatic) ramus winds around the pedicle to supply dorsal structures, the sinuvertebral nerve re-enters the intervertebral foramen to supply the same dorsal vertebral structures - posterior disc, facet joint, ligaments, and dura mater including the ligaments and dura of the intervertebral foramen (Bogduk, 1988). Looking at figure 4,and sticking t o the sympathetic system, one can see that pain or symptoms in the arm could be due to:
0 Entrapment of segmental spinal nerves which are carrying afferent fibres from sympathetic nerves. Entrapment o r ischaemia of sym-pathetic nerves, eg over rib necks or osteophytes.

Fig 3: Collapsed and osteoporotic thoracic spine of 87-yearold; shows right sympathetic trunk on neck of ribs, large osteophytes from costo-vertebral joints, and visceral branches stretched over and around osteophytes

Referred pain from the heart, oesophagus, etc.

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Department of Ultimate Causes

Why should a joint pain be referred along sympathetic nerves rather than somatic nerves? Some clinicians have found that long-standing visceral problems have been alleviated incidentally when treating spinal problems. Perhaps sustained o r extreme postures lead to relative ischaemia, and the result is a kind of repetitive strain injury, but with sympathetic symptoms. So it may be that in a T4 syndrome, it is not the joint that is in trouble, but the arteriole. The scenario most likely to produce arteriolar ischaemia is repeated injury and repair, with its mixture of scar formation, recurrent damage, attempted repair, and patchy proliferating inflammatory tissue - in other words, in ordinary ageing and ordinary over-work, when old enough t o have some chronic damage, but still active enough t o be causing further damage.
Author and Address for Correspondence Dr P Evans MB BS is a clinical assistant in the Accident Unit at
Norfolk and Norwich Hospital, Norwich, Norfolk NR1 3SR.

Fig 4: Distributiono upper thoracic sympathetic nerves f

Appeal

Referred pain from a thoracic spinal structure, and in the neck a dorsal spinal structure.
0

0 Referred pain from any structure in the forequarter.

The author is collecting data on this subject. If any therapist is willing to provide (patient anonymous) data on one sheet of A4 paper for any T4 patients seen, please leave an address or fax number on fax 01603 593166 or telOl603 593074.

Acknowledgments
Thanks to the following for patient help and instruction: Jackie Critchley, Sheila Crowley, Greg Grieve, Jill Guymer, and Sue Montgomery, plus countless others who have put up with my questions. This article was received on July 15, 1996, and accepted on September 11, 1996.

Thus sympathetic nerves provide a path for the expression of the T4 syndrome, the pain referral occurring, as in somatic nerves, from a proximal structure supplied at one level t o a peripheral structure supplied at the same level. Most experienced clinicians will recopi se sympathetic-type symptoms when they meet them, and expect t o find the cause in posterior spinal structures. The heavy arm that feels puffy or swollen, the band pain tight around the arm, and the creeply-crawly feelings are especially memorable symptoms. The pathway for referral of pain from the joint of the shoulder girdle to the thenar eminence is similar.

References
Bogduk, N (1986). Research design or What is a T4 syndrome? New Zealand Journal of Physiotherapy, December, 9-1 1. Bogduk, N (1988). Innervation and pain patterns of the thoracic spine in: Grant, R (ed) Physical Therapy of the Cervical and Thoracic Spines, Churchill Livingstone, Edinburgh. Caillet, R (1981). NeckandArm Pain, F A Davies Co, Philadelphia, 2nd edn. Ebbetts, J (1971). Autonomic pain in the upper limb, Physiotherapy, 57, 6, 270-279.

Other Autonomic Presentations in Disease

Disorders of the autonomic nerves occur as part of a general neuropathy, notably in diabetes mellitus. Autonomic dysfunction is then manifested by postural hypotension (the blood pressure drops on standing up, due to failure of the sympathetic system t o increase vascular tone in response to the baroreceptors in the jugular vein), disorders of sweating, and peripheral puffiness or oedema.

Grieve, G P (1981). The autonomic system in vertebral pain syndromes in: Grieve, G P Common Vertebral Joint Problems, Churchill Livingstone, Edinburgh, 2nd edn, pages 319-329. Grieve, G P (1986). Modern Manual Therapyof the Vertebral Column, Churchill Livingstone, Edinburgh. McGukin, N (1986). The T4 syndrome in: Grieve, G P Modern Manual Therapy of the Vertebral Column, Churchill Livingstone, Edinburgh. Smith, K L (1991). Unpublished MACP Project, personal communication, Leicestershire. Williams, P L, Warwick, R , Dysqn, M and Bannister, L (eds) (1989). Grays Anatomy, Churchill Livingstone, Edinburgh, 37th edn Segmental Sympathetic Supplies, page 1167.

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