Spinal Tumour – Thoracic
SpineOverview
Thoracic spinal tumours are abnormal growths within or adjacent to the thoracic spinal cord and vertebral bodies, presenting as either primary neoplasms or secondary metastatic disease. These tumours pose significant neurological risk due to spinal cord compression and require urgent medical investigation and management. Early recognition of red flag symptoms is critical for preserving neurological function and optimising treatment outcomes.
Pathophysiology
Thoracic spinal tumours develop through malignant cell proliferation within the spinal canal, vertebral bodies, or surrounding tissues. Primary tumours arise from spinal cord cells (ependymomas, astrocytomas) or supporting structures (meningiomas, schwannomas), while metastatic disease spreads from distant primary cancers (lung, breast, kidney) via haematogenous or lymphatic routes. Progressive tumour growth causes mechanical spinal cord compression, vascular compromise, oedema, and demyelination, leading to progressive neurological deficit. The thoracic spine's rigid anatomy and limited space exacerbate compression effects, making early intervention essential to prevent irreversible cord damage.
Patient Education
Spinal tumours are serious conditions requiring urgent specialist investigation; any progressive neurological symptoms, night pain unresponsive to rest, or unexplained weakness warrant immediate medical evaluation to prevent permanent disability.
Typical Presentation
Site
Mid-back (thoracic region T1-T12), often unilateral in early stages; may radiate in dermatomal distribution depending on nerve root involvement
Quality
Deep, aching, or burning pain; progressive neurological symptoms including numbness, tingling, or weakness in lower limbs and trunk
Intensity
Variable onset; initially mild and progressive, often worse at night or with recumbency; may escalate rapidly depending on tumour type and growth rate
Aggravating
Lying flat, Valsalva manoeuvre (coughing, straining), activity that increases intracranial pressure, spinal movement in advanced disease
Relieving
Upright posture may provide temporary relief; typically minimal response to conventional pain management
Associated
Progressive lower limb weakness, gait disturbance, bladder/bowel dysfunction, loss of temperature sensation, spasticity, pain disproportionate to physical findings, constitutional symptoms (weight loss, night sweats, fever in some cases), kyphotic deformity if vertebral body involvement
Orthopaedic Tests
Night Pain Assessment
Procedure
Ask whether the pain wakes the patient, whether it is there regardless of position, whether it is steadily worsening, and whether simple pain relief helps. Ask about cancer history, weight loss and feeling unwell.
Positive Finding
Constant, progressive thoracic pain not eased by rest or position change, especially with a cancer history or unexplained weight loss.
Interpretation
Night pain alone is a weak warning sign, but thoracic pain is less often mechanical than low back pain, so the threshold for concern is lower. With a cancer history, weight loss, age over 50 or failure to improve, arrange prompt medical review and imaging.
Palpation for Midline Tenderness & Step-off Deformity
Procedure
Patient prone or seated. Palpate along the thoracic spinous processes, noting focal bony tenderness, a step, swelling or a mass. Tap gently over each spinous process.
Positive Finding
Sharp, focal bony tenderness, a new angular step, or a palpable mass.
Interpretation
Not diagnostic, but in a patient with red flags it raises concern for a bony lesion or fracture and supports urgent medical referral for imaging.
Neurological Screening (Motor & Sensory Examination)
Procedure
Test lower-limb strength, sensation and reflexes, and map any band of altered sensation on the trunk (a sensory level). Common landmarks: T4 at the nipples, T10 at the umbilicus.
Positive Finding
Weakness in both legs, a sensory level on the trunk, or brisk reflexes in the legs.
Interpretation
These findings suggest spinal cord compression. In a patient with suspected tumour this is an emergency: arrange same-day medical assessment for urgent MRI.
Myelopathy Screening (Babinski Sign, Clonus, Hyperreflexia)
Procedure
Stroke the outer sole of the foot from heel towards the little toe and across the ball of the foot. Test for ankle clonus by briskly dorsiflexing the ankle. Compare knee and ankle reflexes on both sides.
Positive Finding
An upgoing big toe (Babinski sign), sustained clonus, or brisk reflexes in the legs.
Interpretation
Upper motor neuron signs indicate spinal cord involvement. With a suspected tumour, they need same-day medical assessment for urgent MRI.
Constitutional Symptom Screening
Procedure
Ask about unexplained weight loss, loss of appetite, fatigue, fevers, night sweats, a past history of cancer and any other new symptoms (cough, blood in urine, breast lump).
Positive Finding
Unexplained weight loss or general illness with new thoracic pain, or a past cancer history.
Interpretation
These findings raise concern for cancer or infection and need prompt medical review with imaging and blood tests, even when the examination looks mechanical.
Straight Leg Raise (SLR) & Slump Test (Limited Applicability in Thoracic Tumour)
Procedure
Perform the straight leg raise on each side and the slump test, noting any leg symptoms, and any spinal pain provoked by neck and trunk flexion.
Positive Finding
Reproduction of leg symptoms, or thoracic pain provoked by the slump position.
Interpretation
Neural tension tests add little to the assessment of a suspected thoracic tumour. A positive result does not point to a tumour; the history, red flags and neurological examination matter far more.
⚠ Red Flags
- •Progressive neurological deficit (weakness, numbness, loss of sphincter control)
- •Night pain unresponsive to rest and analgesia, especially with awakening from sleep
- •Acute onset of lower limb paralysis, urinary retention, or faecal incontinence (cord compression emergency)
- •Spasticity with hyperreflexia and Babinski sign (upper motor neuron signs indicating cord involvement)
- •Loss of temperature sensation or level-specific sensory loss
- •Severe, unremitting thoracic pain in patient with history of cancer
- •Kyphotic deformity or vertebral collapse visible on imaging
- •Age <5 or >70 with progressive spinal pain
- •History of malignancy with unexplained spinal symptoms
- •Pain worse supine or with recumbency
- •Constitutional symptoms (weight loss, fever, night sweats) accompanying spinal pain
⚡ Yellow Flags
- •High health anxiety or catastrophising regarding spinal symptoms
- •Significant psychosocial stressors or depression affecting coping mechanisms
- •Pending serious medical diagnosis with associated psychological distress
- •History of cancer with ongoing concerns about recurrence
- •Social isolation limiting support systems during illness trajectory
- •Work-related stress or fear-avoidance regarding physical activity
- •Poor adherence to medical follow-up or specialist investigations
Osteopathic Techniques
Region
Thoracic spine and surrounding musculature
Technique
Rationale
Gentle soft tissue mobilisation of paraspinal muscles and fascia reduces secondary muscular guarding and improves local circulation, supporting overall comfort and assessment capacity without exacerbating cord compression risk
Region
Thoracic cage and costal articulations
Technique
Rationale
Gentle costal and thoracic articulation maintains respiratory mechanics and reduces compensatory thoracic restriction, optimising breathing capacity and reducing secondary musculoskeletal dysfunction
Region
Lumbar and cervical spine
Technique
Rationale
Treatment of adjacent spinal regions addresses compensatory patterns and secondary myofascial dysfunction, reducing overall load on compromised thoracic segments
Region
Thoracic lymphatic drainage pathways
Technique
Rationale
Gentle lymphatic drainage techniques support immune function and fluid management, potentially reducing localised oedema surrounding the lesion; must be performed with caution and appropriate medical coordination
Region
Craniosacral system
Technique
Rationale
Gentle craniosacral technique may support cerebrospinal fluid circulation and reduce intracranial pressure effects; performed conservatively as an adjunct to conventional medical management
Region
Intercostal spaces and thoracic fascia
Technique
Rationale
Functional technique addressing thoracic cage mechanics optimises respiration and reduces secondary strain patterns without direct manipulation of potentially unstable segments
Rehabilitation Exercises
Thoracic Spine Gentle Extension in Sitting
Thoracic Rotation Stretch (Quadruped with Hand Behind Head)
Diaphragmatic Breathing with Hand on Abdomen
Thoracic Posture Awareness – Seated Back Against Wall
Child's Pose – Gentle Thoracic and Lumbar Stretch
Standing Balance – Feet Hip-Width Apart, Eyes Open
Prone Hip Extension – Single Leg Lift (If Neurologically Appropriate)
Seated Proprioceptive Retraining – Weight Shifts
Quadruped Marching – Alternating Knee Lifts
Upper Back Muscle Activation – Prone Thoracic Lifts
Tandem Stance – Progressive Balance Challenge (As Tolerated)
Sit-to-Stand Training – Functional Transfer Practice
Referral Criteria
- •Any patient presenting with progressive neurological deficit, spasticity, or upper motor neuron signs – refer immediately to spinal surgeon/neurosurgeon
- •Acute onset of lower limb paralysis, urinary retention, or faecal incontinence – EMERGENCY referral to emergency department for spinal cord decompression assessment
- •Night pain unresponsive to analgesia with progressive course – refer to medical doctor for imaging and oncology consultation
- •History of malignancy with new or progressive spinal symptoms – refer to oncology and spinal surgery for investigation
- •Pain out of proportion to physical examination findings with constitutional symptoms – refer to general practitioner for systemic investigation
- •Suspected vertebral collapse or kyphotic deformity – refer to spinal surgeon for stability assessment
- •Patient requiring surgical or radiation oncology intervention – coordinate care with relevant specialists
- •Neurological decline at any point - EMERGENCY referral for MRI and oncology/spinal surgery assessment. A suspected or confirmed spinal tumour is not a condition managed conservatively with manual therapy; neurological decline suggests metastatic cord compression and is time-critical.
- •Post-operative or post-radiotherapy complications – refer to treating oncology/surgical team
- •Patients requiring pain management optimisation – refer to pain specialist or palliative medicine team as appropriate