Identifying T4 Syndrome

Joseph,

Great post! When you get the chance, go to the Magee Orthopedic Examination text and look up tension points and you will be pleasantly surprised to find a diagram taken from David Butler’s book The Sensitive Nervous System. The tension points of the spine where there is minimal excursion of neural tissue are C6, T6, and L4. This along with T4 are all key areas. It’s always amazing when someone comes in to see me and they present with adverse neural tension in the median nerve and I do a manip directed at T6 and miraculously there neural tension goes away almost immediately. Where are only scratching the tip of the iceberg. Would love to chat more with you on this topic. Keep up the good work. Go Steelers!!!

Very interesting! Does anyone know if there anything on this happening with lower thoracic regions and influencing the LE sympathetic system with sudomotor and pain symptoms as a differential diagnosis for CRPS I (formerly RSD)? The influence of this region on the sympathetic nervous system has potentially far reaching systemic impact.

I agree with you both. I see this diagnosis a great deal, and my most successful treatments have been the screw and/or pistol manipulation directed at T3-T6. If tolerated, a home program of rolling on a foam roll can really help as well. Prone press ups work well, and once mobility is restored, stability exercises help to keep this new posture.

Occasionaly, I’ve found the patient to have some very minor sternocostal pain. Frequently, the patient will have a forward head/rounded shoulders posture.

Philip Greenman states that he often observes a ‘red response’ from stroking of the skin over the paraspinals, reflecting an abnormal vasomotor response.

Mark Dutton’s Orhtho text describes T4 syndrome.
He states that the symptoms seem to resolve from manual therapy to the segment. He states that neurovascular symptoms are not present, in contrast to Greenman. He states that nocturnal symptoms are common as well, especially during sidelying or supine.

David Butler recommends using both upper limb tension tests and the slump test. These, he says, can be combined with thoracic sidebending and rotation.

Great topic.
Go Steelers!

If you go to Magee’s new book you will find a chapter we wrote on exactly this and more – we have been all over the thorax for neck and shoulder pain for years – there is a lot of clinical expertise in this area and an evolving body of evidence – check out this chapter and check out our courses at http://www.discoverphysio.ca if you want the leading edge info on the Thorax!
Lee L J, Lee D L 2008b Integrated, multimodal approach to the thoracic spine and ribs. In: Magee D J, Zachazewski J E, Quillen W S (eds) Pathology and intervention in musculoskeletal rehabilitation Saunders, Elsevier p 306
Diane Lee & Linda-Joy Lee
Discover Physio

I have treated many patients over the years with this condition. It was well described in the 80’s by Maithland in his vertebral book. I usually use acupuncture, (HJJ, IB &OB) at T3456, plus manips, and rhythmical rotation and ext exs. It resolves very well. There have been several papers in the acupuncture journals about this.

I have found that mobilization of the upper and mid thoracic through gentle muscle energy and progressing to grade V in conjunction with strain / counterstrain techniques works well with these patients. They ususally have been misdiagnosed with CRPS or multiple cervical facet inflammation.

What is the differential diagnosis difference between T4 Syndrome and Thoracic Outlet Syndrome? Thanks, this is a very interesting topic.

Leigh,
Great question. I have actually discussed with a colleague how to differentiate a neurogenic TOS from T4 syndrome but haven’t seen great evidence in doing this. I see both diagnoses as diagnoses of exclusion and I would go through the standard TOS tests (Adsons, ROOS) to look for the diminution of a pulse (which has a high sensativity for TOS) to diagnose a vascular + neurogenic TOS. Because of the C8-T1 nerve roots which come from the lower trunk of the brachial plexus, I would also expect one with TOS to have more 4th/5th digit issues. I would also examine the scalenes and look for the presence of a cervical rib in which I would also lean towards TOS. In both cases, you can have sympathetic disburances and thoracic pain. So I would first attempt to rule out TOS, and if you can, I would sway on the side of T4 syndrome. Now this is my clinical thinking and others of you may approach this different. If so, please let us know….

Robert Fraser MD , is a long-lived specialist in Orthopedic Medicine (Cyriax) near Buffalo. In 1978, he wrote one of the first papers, “T-3 syndrome” in a non defunct journal.

I can send a copy to however wants it.

Dr. Abraham,
Shoot it over my way…joebrence9@hotmail.com

Dr. Abraham,
Could I please have a copy of the T3 syndrome paper?

hstark@msmoc.com

Thank you.

Dr. Abraham, Could I have a copy of the T3 syndrome paper as well? Thank you.

T3 syndrome

Donald M. Fraser
________________________________________________________________

A syndrome is described consisting of upper back pain associated with an area of muscle hypertonicity at the thoracic 3 (T3) spinal level; loss of joint play at this level (thoracic disc derangement) and autonomic nervous system changes in the upper extremity which may include paresthesias, muscle weakness and vasomotor responses in a non-dermatomal pattern.

The ‘T3 syndrome’ may be mistaken for brachial plexus injury, cervical disc syndromes, thoracic outlet syndromes, carpal tunnel syndrome, Raynaud’s phenomenon, cardiac or chest pathology. This segmental dysfunction can be treated with manipulative reduction at the T3 spinal segment and, if recognized early, may preclude unnecessary and expensive diagnostic studies and untoward delay in treatment.

CASE STUDY 1

This condition was brought to my attention by this case. A 32-year-old female injured her neck, upper and lower back in a motor vehicle accident and presented with signs of sacroiliac joint torsion. A prominent part of her symptom complex was pain in her upper back; palpable muscle hypertonus at T2, T3 and T4 in her paraspinae muscles. She also complained of difficulty with her hands, more marked on the left than on the right. The left middle and ring fingers were white and swollen (middle finger, distal from the interphalangeal joint and distal segment of the ring finger). An atypical Raynaud’s phenomenon was suspected. Manipulation of the T2, T3 and T4 levels was performed using techniques described by Bourdillon1. This produced immediate return of colour and warmth to the affected fingers and a beginning of clearing of the hand swelling. Since that initial episode, on recurrence of symptoms and signs not related to temperature change (hot or cold) return to normal function can be achieved by manipulative treatment at the T3 (or appropriate) level.

A second case served to amplify the symptoms associated with this syndrome.

CASE STUDY 2

A male weight-lifter complained of easy fatiguability of his right arm on repetitive bench pressing. The cardiovascular system was normal; testing against resistance showed no loss of muscle strength on either side. Historically, he could perform 25 repetitions without difficulty on the left side. In contrast, the right side, historically ‘wore out’ with 4-5 repetitions. Physical examination revealed sacroiliac torsion from an old injury and an area of muscular hypertonus at T3 with joint dysfunction (thoracic disc derangement) on the right side. He was pain free before examination, so the results of manipulative reduction to T3 and the sacroiliac joints could not be established immediately as usually happens. He reported full function and power within 24 hours. This made the connection with power loss as part of the ‘T3 syndrome’.

DISCUSSION

These cases and subsequently other have caused me to postulate a ‘T3 Syndrome’. This is similar to the T12 or thoraco-lumbar syndrome described by Robert Maigne2.

Anatomy

According to the dermatome charts of the Textbook of Orthopaedic Medicine3, there is a small segment of T3 along the axillary area of the arm, but not extending far enough distally to account for the findings that appear to be vasomotor-related. The thoracic segments connect liberally with the sympathetic ganglion at T2 and the sympathetic chains and may be the source of the signs and symptoms.

Presenting problem

There is a history of trauma; often a motor-vehicle accident of the rear-end impact type; a fall on the tucked-in shoulder or a direct blow to the shoulder and upper thorax (anteriorally or posteriorally). The complaints are some or all of the following:

- Pins and needles in some or all 5 fingers;
- Swelling of all or some of the finger or hand (rings are tight);
- Aching deep in the upper arm, forearm, wrist or thumb, anterior chest;
- Color changes in hand and/or fingers;
- Weakness or easy fatiguability of muscles of shoulder, forearm or hand;
- Loss of active and passive extension of shoulder with inability to reach above head or behind back (cannot fasten brassiere at back);
- Unable to lie flat on back (shoulder is forward and clavicle prominent);
- Aching down arm with restricted range of movement of shoulder joint (a secondary capsulitis of gleno-humeral and/or acromio-clavicular joint).

CLINICAL FINDINGS

(1) All six active movements of head and neck do not produce or aggravate the symptoms.

(2) All tests for acromio-clavicular and gleno-humeral joint are non-capsular or equivocal.

(3) Tender paraspinae areas of muscular hypertonus at one or more levels T2, T3 or T4, sometimes associated with areas of muscular hypertonus over the costo-transverse junctions at the same levels.

(4) Tenderness and sometimes palpable displacement of the rib of the same segment anteriorally. This finding often results in an expensive, intensive and negative investigation.

(5) Observable swelling and colour changes on affected limb or hand (fingers).

(6) Weakness on resisted testing of more than one muscle and dermatomal origin, i.e. supraspinatus (C5), biceps (C5,6), triceps (C7), abductor pollicis (C8) (grip-strength); it is necessary to rule out a brachial plexus lesion.

(7) Non-capsular pattern of restricted passive movement – gleno-humeral joint, i.e. abduction 90°, lateral rotation 90° and medial rotation 50°.

(8) All other arm tests negative.

(9) May or may not have sacroiliac torsion.

TREATMENT

Manipulation of the detected lesion, i.e. T2 and/or T3 and/or T4, results in a dramatic and rapid clearance of signs and symptoms and return of power and improved range of movements in gleno-humeral joint. If there is residual capsular pattern of joint arthritis (arthrosis), it must be treated in the usual orthopaedic medicine3 protocol. If a costo-transverse junction dysfunction is present, it too responds to manipulative reduction described by Bourdillon. The fulcrum is moved laterally over the area of hypertonus; it can also be manipulated and reduced using an anterior approach. If marked ligament laxity is present with recurrences of the problem due to the joint instability, it is necessary to include ligament-strengthening injections, i.e. sclerotherapy (prolotherapy in the United States).

PROGNOSIS

Prevention of recurrence is difficult owing to the nature of the affected levels – and the pull of the arm muscles on the ribs. The ligaments are often stretched and lax owing to the trauma and aggravated by imprecise therapy before the diagnosis is made.

REVIEW OF LITERATURE

A review of the literature revealed that this phenomenon was reported by John Bourdillon, in 19854 and in addition, under the direction of Robert Kappler, at the Chicago College of Osteopathic Medicine, thermographic studies of the T3 area and the secondary vasomotor effects are showing early correlation5.

REFERENCES

1. Bourdillon, J.F. (1982). Spinal Manipulation 3rd edn. (New York: Appleton-Century- Crofts)
2. Maigne, R. (1981). Le syndrome de al chaniere dorsolumaire (the thoracolumbar junction syndrome: low back pain, pseudo-visceral pain, pseudo-hip pain and pubalgia). Sem. Hosp. Paris, 57, 11
3. Cyriax, J. (1978). Textbook of Orthopaedic Medicine, Vol.1, Diagnosis of Soft Tissue Lesions (7th edn.). (London: Baillière Tindall)
4. Bourdillon, J.F. (1985). Proceedings of the Annual Meeting of the International Federation of Manipulative Therapists, Vancouver, British Columbia, Canada
5. Kelso, A.F. (1985). Recent research in thermography. Paper presented at the Annual Meeting of the North American Academy of Manipulative Medicine, Edmonton, Alberta, Canada

Fraser, D.M.: Back Pain, An International Review; Kluwer, 1990. Chapter 51.

As regards your interest in the T4 syndrome (also known as the T4 costo-transverse syndrome) I am enclosing a copy of Dr. Fraser’s article “WHIPLASH WHAT ELSE IS IT?? A Total Body Approach”, a paper given before the Society of Apothecaries of London in 1994.

Dr. Fraser was kind enough to give me a copy of this paper before he died.

One of his last published papers was Vignette of a Clinical Practice, Thoughts from Canada, written with his colleague Jane Stevens, MCSP, MSOM, published in The Journal of Orthopedic Medicine 29 [2] 2007 51-56.

WHIPLASH -WHAT ELSE IS IT??
A Total Body Approach!
PREAMBLE:
THE SUBJECT OF “WHIP-LASH” HAS BEEN OVERWORKED RECENTLY DUE TO THE SERIOUSNESS OF THE PROBLEMS WHICH OCCUR AT THE TIME OF THE INJURY AND THE INABILITY OF THOSE PHYSICIANS AND NON-PHYSICIANS TO WHOM THE PUBLIC TURNS FOR COMFORT AND DEFINITIVE TREATMENT TO CORRECTLY DIAGNOSE THE ORIGINS OF THE SYMPTOMS. WHAT APPEARS TO BE A DILEMMA FOR THOSE TREATING THE ACCIDENT PATIENT (I HESITATE TO USE THE WORD ‘VICTIM’ DUE TO THE HOST OF NEGATIVE CONNOTATIONS ASSOCIATED WITH THIS TERM) IS THE LACK OF FINDINGS ON VARIOUS METHODS OF IMAGING EG. CT SCANS; ROUTINE X-RAYS; MRI SCANS AND MOST RECENTLY PET SCANS WHICH UNLESS THEY DISCLOSE FRACTURES OR SEVERE DISLOCATIONS ARE NOT WITHIN THE SCOPE OF ORTHOPAEDIC PHYSICIANS. THIS LEAVES THOSE PRACTITIONERS IN THE SAME SITUATION AS THE LATE DR. JAMES CYRIAX FOUND HIMSELF IN 1929 WHEN HIS PROFESSORS WERE A “LITTLE LESS THAN CRISP” IN THEIR MANAGEMENT OF PROBLEMS OF THE MUSCULO-SKELETAL SYSTEM IN THE FACE OF “NEGATIVE” OR EQUIVOCAL X-RAYS. WE ARE THUS FORCIBLY BROUGHT BACK TO THE FUNDAMENTALS OF ALL MEDICINE – A GOOD HISTORY AND PHYSICAL EXAMINATION! TO THOSE OF US WHO HAVE BEEN BLESSED BY EXPOSURE TO DR. CYRIAX, THE BURDEN IS DRAMATICALLY LESSENED USING “APPLIED ANATOMY” AND LOGIC.
PLAN OF APPROACH: (sequence of examination).
1. FOOT: for subluxation (loss of joint-play) of Cuboid bone;
2. SUPERIOR TIBIO-FIBULAR JOINT: for loss of joint-play;
3. KNEE JOINT: for detection of “springy-block” on passive examination;
4. SACRO-ILIAC JOINTS: for subluxation and mal-position;
5. LUMBAR SPINE: for damaged lumbar discs;
6. THORACIC SPINE: for Right-Left-Right Muscular- Imbalance syndrome;
7. THORACIC SPINE: for T-3 Syndrome;
8. CERVICAL SPINE: for Cervical disc derangements;
9. CERVICAL SPINE: for the Posterior Cervical Syndrome of Barré: associated with Cervical Discs at C2/3 and C3/4 levels.
When one thinks of “whip-lash” injuries, the immediate assumption is that all you assess and treat is the neck’s soft-tissue damage. The patient has had routine x-rays of the neck which usually do NOT show any fractures but often show a “straightening” of the cervical spine indicative of muscle spasm. This information is useful as it confirms that there has been a soft-tissue injury and that the muscles are responding. As the late Dr. James Cyriax1 used to say “All muscle spasm is secondary” – therefore, you must locate and treat the primary source of the spasm, if you expect to benefit the patient.
My subject allows me to look for other areas of injury associated with “Whip-Lash” injuries. At a meeting of the American Association of Orthopaedic Medicine in San Diego, California, some years ago – an Orthopaedic Physician2 pointed out that it was mandatory to check the feet in all cases of car accident as the force comes up through the floor board of the vehicle and travels through the body to the neck.
1 CYRIAX, J: Textbook of Orthopaedic Medicine; Edition 7; Bailliere and Tindal;
2 RAVIN, T: Presentation -American Association of Orthopaedic Medicine: San Diego, 1989.

Page 2.

He showed us a simple test for the integrity of the Cuboid bone which is the keystone of the arch and is often subluxed in car accidents. Interestingly enough – this problem would also be picked up by Dr. Cyriax’s examination of the foot and ankle. The sign of subluxation or loss of “joint-play”3 is a loss of eversion – performed passively, of the fore-foot at the mid-tarsal joint as compared with the “normal foot”. This, once detected, can be readily reduced using a very simple manipulation (mobilization) thus returning the foot to normal integrity. Care must be taken in the patient who has had more than one Motor Vehicle Accident (MVA) for there can be subluxations bilaterally. The patient tends to walk on the out-side of the foot following injury, producing excessive wear on the outer aspect of the shoe on that side. As the Cuboid bone is surrounded by proprioceptors, a mal-function there will affect the patient’s ability to balance on one foot.
On arriving back in St.Catharines, Ontario from San Diego – I was very doubtful of the frequency of this phenomenon and checked the next 26 patients with a history of “Whip-Lash”. After finding 25 out of 26 positive for this sign, I telephoned my colleague in Denver to confirm his observations – He was not at all surprised!
As the force spreads up the leg, the next joint which can and does become subluxed is the Superior Tibio-Fibular joint. As you recall the Fibula, at the ankle, must rotate outwards 30° to allow for the wider aspect of the Talus to nest between the Tibia and Fibula on dorsiflexion.4
This action depends on the Fibula displacing cephalad and when this joint is damaged – the patient has a “shortened” Tendo-Achilles on the affected side and must turn the entire foot outwards to allow the foot to touch the floor. This produces a gait similar to “Charlie Chaplin” and can have a detrimental effect on the bodies’ balance.
A patient of mine had this phenomenon plus the subluxed Cuboid bone and when both were restored to normal joint-play – she told her friend in the waiting room “This is the first time I have had my foot flat on the floor since the accident”. The manipulation again is very simple.5 The patient lies prone and the operator flexes the knee to 90° and applies his hands at the popliteal crease with his hands overlapped and applies a gentle traction toward himself for 10 seconds. Maintaining the traction, he exerts a sharp short tug, then the joint excursion is retested. If the joint play has been restored to full range – no further treatment is indicated. None of the 25 positive patients for subluxation of the cuboid or those with subluxed superior Tibio-Fibular joints were complaining of their feet or legs. Some of the latter group noted an ache occasionally on the outer side of their leg at the knee which they attributed to the knee. Another complaint was a sore Great Toe and soreness along the inner aspect of the ankle – sometimes mimicking a Plantar Fasciitis.

3 MENNELL, “Joint Pain”, Little Brown, 1964.
4 KAPANDJI, I.A: The Physiology of the Joints. Vol.2: E&S Livingston. 1970: Page 152.
5 NICHOLAS, N.S.: Atlas of Osteopathic Techniques. Philadelphia College of Osteopathic Medicine, 1974. Page: 60.

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The next joint to be involved in the upward force is the Knee. It often is damaged, by striking the dash-board. A common finding on examination is a blocked movement on passive prone-lying flexion of the knee with a “springy” end-feel.” Those of you who have not taken a Cyriax course will find this concept new to you but it is one of the many useful signs which Dr. Cyriax discovered and described. This sign – when found, denotes a “loose body” blocking the joint and it too responds rapidly and readily to manipulative reduction6. Occasionally this sign is accompanied by swelling and heat on examination. This should not deter you unless it is an acute trauma case where it is important to rule out blood in the fluid. Blood is a very major irritant and should be aspirated when found.
The next level to be checked are the Sacro-iliac joints which we were all taught do not produce problems except in pregnancy and in severe injuries eg. falling from a airplane.
Unfortunately Grey’s Anatomy7 description of two – 70 year-old male cadavers both of whom had partial fibrosis of these joints and partial synovial areas, was classified as “NORMAL”. This dogma has led to a lot of confusion among medical people. This error has been exploited by the non-medical manipulators who recognized that indeed these joints are a source of problems and can be satisfactorily treated. An article by Cassidy and Bowen8, working in Saskatchewan with Dr. Kirkardy-Willis, shows quite clearly that these joints are synovial from before birth up until at least 90 years of age.
A study was done by R. Barbor, MB.9 in Mainz, Germany, where a group of 200 walk-in patients with “low-back pain” were examined using the Cyriax plus Barbor examination and found that 60% had sacro-iliac torsion. It is thus, a very common problem but, fortunately, the manipulations that Dr.Cyriax taught for the lumbar discs have a salutary effect on the sacro-iliac joints as well. He states in Volume 2 of the Textbook of Orthopaedic Medicine, that the distraction manipulation for the lumbar disc results first “in a click, which is ligamentous and the second “thunk” is the disc”. The detection of Sacro-iliac Torsion can be learned and is now taught in Cyriax courses. It is my habit to assess the patient in the standing position for the levels of the anterior superior iliac spines (ASIS). This detects both an imbalance in the levels of the ASIS and the possibility of an anatomical short leg. The patient is also assessed from the posterior approach looking again for the levels of the spines – this time the Posterior Superior Iliac Spines (PSIS) are checked.

6 CYRIAX, J.: Textbook of Orthopaedic Medicine, Vol.2, 11th Edit. Page: 227. Bailliere, Tinda1; 1984.
7 Grays Anatomy; Churchill Livingstone, 1946.
8 BOWEN and CASSIDY: Spine: Vol.6, No.6 November/December 1981 pages 620-628.
g SLATTER, Peyto: Presentation North American Academy of Manipulative Medicine, Toronto, 1977.

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They may be not level and an additional test is the “Lock Sign” which is performed by placing the examiners fingers lightly in the PSIS and having the patient bend forward slowly. The PSIS should move together! If not, you have a Sacro-iliac problem. The type of problem is further defined in the supine position. The examiner is looking for the positions of the ASIS to determine if there is indeed a short leg. The spines will be level if there is a short leg. The type and extent of the torque must be defined in order to affect reduction.
The next level to be assessed is the Lumbar spine. It is important to check this area as it often is damaged in a motor vehicle accident (MVA) but does not show up clinically for some months or years. Good examination notes can be invaluable to your patient if and when there are symptoms in the lumbar spine and its relationship to the accident is challenged – usually by the Insurance companies.
The areas to check include the PSIS which can be warm and swollen in the presence of an underlying lumbar disc derangement. The swelling is detectable by palpation and may be the site of referred pain for the patient. This sign does NOT tell what level, what side nor how big the lesion is, but the usual Cyriax10 examination of the lumbar spine may or may not show neurological deficits relative to the severity of the damage to the Lumbar spine. Palpation at each level of the Lumbar spine will show a tender area of muscular hypertonus at the affected level(s).
Secondary to the Sacro-iliac Torsion – the body produces an idiopathic Scoliosis which is a compensatory reaction secondary to the pelvic imbalance and largely clears with the correction of the Sacro-iliac Torsion. This scoliosis has areas of muscular hypertonus – usually located over T12, T6, and T3 levels. This is related to the effort of the body to keep the balance organs and the eyes in the same plane. The Osteopaths profession in America are calling these “cross-over” patterns. These hypertonic levels are often the site of complaint – of pain which makes it important to check the rest of the body as these levels are often secondary and will NOT clear without the release of the other affected levels.
A common syndrome not readily noted is the T3 or Costo-transverse Syndrome11 which manifests itself by pain down an arm; pins and needles affecting up to 5 fingers (often mistaken for Carpal Tunnel Syndrome); vaso¬motor instability of the affected limb; oedema of the ulnar groove on the affected side; weakness on resisted testing of the thumb adductor (which is usually stronger than any examiner); Supraspinatus, Biceps,Triceps muscles associated with an area of muscular hypertonus at the T3 and/or the T3 Costo-transverse junction. This phenomenon can also occur at the Thoracic 2 or Thoracic 4 levels and should be searched for when the dramatic clearing of signs and symptoms do not clear with manipulative reduction of the T3 segment. There is often anterior chest wall pain usually at the T3 level on the affected side. The patient may have noticed that the
10 CYRIAX. J. ibid.
11 FRASER. D.M.: BACK PAIN, AN INTERNATIONAL REVIEW: Kluwer, 1990. Chapter 51.

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affected shoulder is forward in the supine position and that the clavicle is raised and sometimes rotated. This syndrome may be seen with falls on the affected side and occasionally by a direct blow on the chest wall. It can and does occur with open-heart thoracotomy. Occasionally, the Sterno-Clavicular joint is also damaged in the “Whip-Lash” episode and joint checked.
This brings me to the CERVICAL area. The most common levels of cervical disc derangements occur at the C2/3; C3/4 levels. These levels are NOT detected by the Cyriax12 cervical spine examination and must be sought on the basis of history. The other common level of neck derangement is C7/T1. This can produce dizziness and pain radiating to the upper dorsal area and a sense of heaviness of the head. It is detected by a loss of range and pain on neck extension. Palpation of the detected level will reveal muscular hypertonus. Obviously any level of the cervical spine can be affected. It follows that perplexing signs can come from more than one level.

I would direct you to “The Posterior Cervical Syndrome of Barré and Leiou”13
published in 1925 in the Journal of Paris in French. I was able to read about it in the book “ORTHOPAEDIC MEDICINE” written by Robert Maignel4 but translated into English.
The syndrome contains among other signs and symptoms: blurred vision with 20/20 vision in each eye separately; hyperaucusis; tinnitus; otalgia; swelling of face and side of neck; dry eyes or mouth; increased secretion of eyes or mouth; mal¬fitting dentures; oedema of salivary glands; dryness on swallowing; altered mentation and asymmetrical opening of jaws. These symptoms are related to the C2/3 level and clear with its release.
If it is the C3/4 level – then there is increased tone in the Trapezius muscle on the affected side. The hypertonus clearing with release of C3/4 level.
MANAGEMENT:
Management of the detected lesions is carried out by manipulation (mobilization) of the appropriate area and instructions are given about avoidance precautions. However, if the accident occurred 10 days before examination and treatment – it has been my observation that the ligaments remain too loose and then you have to rely on Sclerotherapyl5 to the affected levels or fusion of the loose segment. This is another topic which is a very important part of ORTHOPAEDIC MEDICINE in the prevention portion of our responsibilities.

12 CYRIAX. J. ibid.
13 BARRÉ J. and LIEOU Syndrome Sympathique cervical posterieur. Paris Med, 15:266,1925.
14 MAIGNE, Robert MD Orthopedic Medicine. Thomas 1992. Chapter18.
15 HACKETT, G.: Ligament and Tendon Relaxation: Charles Thomas; 1991.

SOCIETY OF APOTHECARIES OF LONDON
1994 FRASER, D.M. “Whiplash – what else is it?? A total body approach!”

Great sharings indeed. I am an ophthalmic surgeon, 30-year-old, and I myself am the T4 syndrome patient, and am now on sick leave for the 2 month already. The reason I’m here is because I am so desperate that I searched everything online about this syndrome. I don’t have the arm symptoms yet, but every other symptom matches the diagnosis of T4 syndrome. I cannot sit or stand > 15 min without feeling the pain and upper back muscle spasms, mainly on the left side. Left side facet joints T4-8 are tender. Can’t drive anymore. I have been undergoing physio for half a year already and it is not improving much despite 2/week sessions (mobilizations, the screw, heat, interferential, acupuncture, postural exercises). I have been told the thoracic spine is extremely stiff. As a result, I also had history of L5/S1 prolapsed disc as well. These problems are now exacerbated after I dislocated my right shoulder recently from tennis. I will be undergoing MRI soon to rule out other differential diagnoses.
I cannot return to work as a surgeon as yet, since I cannot even cope with normal daily activities. Are there any other treatment options? What is the difference between a physiotherapist and a chiropractioner? What is the prognosis? Has anyone come across patients with similar chronicity as I do?

I’ve had t4 syndrome for over two years now. Pt, shots in the neck, more Pt.. Is this normal? Everything I’ve read says a few Pt visits and all is better.

try facet injections at the T3-5 levels or whatever level is causing pain

T4 syndrome is a very common occurrence. Palpably the most common finding will be either T4 anterior T5 or T3 anterior on T4. Whichever side is the most affected we usually have dislocated vertebrae rotated towards that side. These are fairly simple to reduce in the supine position by blocking on the high side vertebrae and then across the rib cage, for example a right rotated T4 anterior on T5, block T5 posteriorly (the high point) then spring through the rib cage front to back, side bending right and forward flexing the spine to make room for the T4 vertebrae to be sprung from anterior to posterior. If further questions contact me.