11 (a) Thoracic Spine: Pathology and Clinical Presentation

Question 1

• Costovertebral joints

Answer 1

• Costovertebral (24)– synovial joints
• Ribs 1, 10,11 and 12 - articulate with single vertebra
• Others ( 2-9) articulate with two + intervening disc

Question 2

Main ligament Costovertebral joints

Answer 2

• Main ligament –radiate ligament

Question 3

Costotransverse Joints

Answer 3

• Synovial joints between ribs and transverse processes

* None for ribs 11 and 12

Question 4

Supporting ligaments Costotransverse Joints

Answer 4

• Supporting ligaments:
• Superior CT lig
• CT lig
• Lateral CT lig

Question 5

Zygaophyseal Joints

• T1

Answer 5

• T1 – transitional joint – superior facet similar to cervical spine

Question 6

Zygaophyseal Joints • T 2- T 11-

Answer 6

• T 2- T 11- Z joints face up, back and slightly lateral

Question 7

Zygaophyseal Joints • T11 and 12

Answer 7

• T11 and 12 – transitional with lumbar spine

Question 8

• Ligaments Zygaophyseal Joints

Answer 8

Ligaments – lig flavum, posterior longitudinal, interspinous,etc

Question 9

Spinous Processes Angle of projection

Answer 9

Angle of projection has implications for thoracic palpation asst
and Rx

Question 10

Spinous Processes

• Angle of projection T 1-3,12

Answer 10

• T 1-3,12 – project directly posteriorly

Question 11

Spinous Processes

• Angle of projection T4-6,11

Answer 11

project slightly downward:
on plane halfway between own TP
and TP below

Question 12

Spinous Processes

• Angle of projection T7-9

Answer 12

T7-9 – tips project downward:
on plane level with TP of vertebra
below

Question 13

Rib Movement With inspiration

Answer 13

• With inspiration ribs pulled up and forward

Question 14

• Ribs 1-6

Answer 14

Ribs 1-6 – increase AP direction chest by rotating round long
axis

Question 15

Ribs 7-10

Answer 15

ncrease lateral dimension by moving up back and
medially =bucket handle movement ( to a lesser degree ribs 2-
6)

Question 16

How do ribs change with age?

Answer 16

• Ribs are elastic in children but become increasingly brittle

Question 17

Mobility of the thoracic spine

Answer 17

• Major function is rotational mobility

* Sagittal movement relatively limited

Question 18

How is sagittal movement limited in Tx spine?

Answer 18

• Sagittal movement relatively limited
– Constrained by vertical Z-joints
– SP approximation in extension

Question 19

Normal thoracic curce

Answer 19

Normal curve 20- 50 degrees

Question 20

Exaggerated thoracic curve -

Answer 20

Dowager’s Hump /Kyphosis

Question 21

What is Scheuermann’s Disease

Answer 21

Uneven growth of thoracic vertebra in sagittal
plane – results in wedging and excessive curvature
This results in decreased height and often increased lumbar
lordosis
• Puts pressure on internal organs but often have very large
lung capacity /broad barrel chests

Question 22

What vertebrae are most commonly affected in Scheuermann’s Disease

Answer 22

• 7th and 10th vertebrae most commonly

affected

Question 23

Lower and upper thoracic curve Scheuermann’s Disease

Answer 23

• Curve in upper thoracic spine – more
disfiguring
• Curve in lower t Tx spine – more painful

Question 24

What is scoliosis

Answer 24

• One or more lateral curves thoracic /lumbar spine

Question 25

Non-structural scoliosis

Answer 25

• Non-structural from poor posture, nerve root irritation, | hysteria, limb length discrepancy, hip contracture

Question 26

Structural scoliosis

Answer 26

Structural – genetic, idiopathic, congenital problem (wedge | vertebra)

Question 27

In which direction do vertebral bodies rotate in scoliosis

Answer 27

Vertebral bodies rotate to the convexity - pushes ribs | posteriorly

Question 28

Indication surgical treatment for scoliosis

Answer 28

• Indicated, in general, for the curve exceeding 45 or 50 degrees by the Cobb's method on the grounds that: • 1) Curves larger than 50 degrees progress even after skeletal maturity. • 2) Curves of greater magnitude cause loss of pulmonary function, and much larger curves cause respiratory failure. • 3) Larger the curve progress, more difficult to treat with surgery.

Question 29

Hx: young (13-16) thoracic presentation

Answer 29

Scheuermann’s Disease /scoliosis (female)

Question 30

Hx: older thoracic presentation

Answer 30

• Older – osteoarthritis /osteoporosis

Question 31

Pain around chest Tx spine?

Answer 31

Costovertebral

Question 32

Pain with digestion Tx spine?

Answer 32

Viscera

Question 33

Tx spine - skin symptoms

Answer 33

shingles

Question 34

Patterns of Mechanical Thoracic Pain

Answer 34

* Cervico-thoracic postural pain * Thoracic spine joint ‘sprain’ (acute) * Acute ‘locked’ joint * Mid-thoracic hypo-mobility disorders (sub-acute/chronic) * Thoracic instability * Thoracic Disc Protrusions

Question 35

Non-mechanical Causes of Thoracic Spine | Pain

Answer 35

``` Fracture – Traumatic – Fragility (related to osteoporosis) • Tumour – Primary - less common – Secondary - spinal metastases more common in thoracic spine • Inflammatory – Inflammatory arthritis • Visceral – Pain referred from abdominal organs ```

Question 36

Visceral Structures Referring

Answer 36

• Lungs – • Lung cancer, smoking, lung conditions , lung surgery, influenza, pleural origin (acute radiating pain any Tx level • Heart – • Cardiac surgery, other heart cond’ns (L T 4-T8) • Abdomen • Gall bladder (R T9) , abdominal surgery, gynaecological surgery (T12, L1) • Kidneys

Question 37

Indicators of Serious Pathology | (Thoracic ‘Red Flags’) Tx Spine

Answer 37

* Severe, constant pain, sleep disturbance * Severe pain post-trauma * Severe pain following minor incident * Constitutional symptoms (low energy, poor appetite) * Unexplained weight loss * SOB/chest pain on exertion * Bowel/bladder dysfunction * P&N’s/numbness in legs or feet * Lower limb weakness/gait disturbance

Question 38

Cervico-thoracic Postural Pain

Answer 38

``` Diffuse cervico-thoracic pain – ± occipital headache • Gradual onset • Increasing pain during day • Worse with sustained postures • Changes in optimal levels of muscle activity – Can be over or under-active • Pain can be from related muscle, points of insertion or loadbearing structures eg. disc ```

Question 39

Thoracic Outlet Syndrome

Answer 39

• Compression of neurovascular structures in the thoracic Outlet (inlet) • Site of compression – Scalene triangle (between anterior & middle scalene muscles) • Subclavian artery & lower trunk of BP – Between clavicle & 1st rib • SC artery or vein & lower trunk of BP – Posterior to pectoralis minor • Axillary artery or vein & one or more cords of BP

Question 40

13 Thoracic Outlet Syndrome Clinical Features

Answer 40

``` • Local pain (Cervico-thoracic) • Distal arm/hand symptoms – P&N’s, numbness, pain • Worse with sitting, carrying objects, overhead activities • Vascular symptoms (less common) – Arterial: coldness, blanching, heaviness – Venous: swelling, warmth, cyanosis ```

Question 41

T4 Syndrome

Answer 41

• Characterised by upper extremity paraesthesia and pain with or without neck and Tx spine S and S’s ( bilateral glove distribution in one or both hands) • Thought to be due to sympathetic NS providing link between Tx spine and the referred symptom pattern

Question 42

Mid thoracic Instability

Answer 42

• Ventral surface TP – deep concave facet for rib at same level • This influences the conjoint rotation that occurs with superior –inferior rib movement • When the rib moves up – get anterior rib rotation • When rib moves down – posterior rotation

Question 43

Instability at CT /CVJ’s Tx Spine

Answer 43

• At EOR, thoracic axial rotation associated with ipsilateral side flexion and vertebral body translation in the opposite direction • At the same time the ipsilateral rib rotates down and posteriorly and the opposite rib rotates up and anteriorly • If lack ligamentous stability at CT and CV joints little resistance to further lateral translation – reliance on muscles • (transversospinalis / ES)

Question 44

Acute ‘locked’ thoracic joint

Answer 44

``` • Similar to cervical wry neck • Thoracic joint ‘locked’ on waking or with trivial incident (low load) • Mid-thoracic segments more common • High pain levels/irritable++ • Significant movement restriction (unilateral) • Pain with respiration Further reading: ```

Question 45

Mid-thoracic hypo-mobility disorders

Answer 45

• Gradual onset or due to unresolved acute pain disorder • Predominantly mid-thoracic segments – Possibly related to disc degeneration • Often more than one segment involved • Sometimes a progression from postural thoracic pain • Commonly bilateral symptoms • Ache at rest, even at night (mild)

Question 46

Mid-thoracic hypo-mobility disorders aggravating factors

Answer 46

• Thoracic spine stiffness in AM – Resolves quickly with activity • Aggravated by sustained postures & end-range movement

Question 47

Mid-thoracic hypo-mobility disorders Movement Impairments

Answer 47

Movement impairments: – Extension, Rotation, Lateral flexion – Impairment of rib movement

Question 48

Early Symptoms of Ankylosing Spondylitis

Answer 48

• Gradual onset of back pain age < 35 years • Pain usually begins in low back & progresses up the spine • Symptoms persist for no obvious reason • Significant morning stiffness and pain that subsides slowly with movement • Pain relieved by movement & not by rest • Fatigue • Plantar fasciitis or achilles tendinopathy • Iritis (Red eyes, pain, light sensitive)

Question 49

Ankylosing Spondylitis

Answer 49

``` Ankylosing Spondylitis – Commonly affects thoracic spine – Gradual onset ache and stiffness (no known cause) • Especially in AM & after activity – Progresses towards loss of mobility and eventual ankylosis of the spine – Strong genetic link (family history) – Blood Test (HLA B27) – Late radiological changes • ‘Bamboo’ Spine ```

Question 50

Thoracic Disc Protrusion

Answer 50

• Serious disc protrusion (requiring surgical management) very uncommon – (<1% of surgically managed disc pathology) • Lower thoracic discs more common • Posterior rather than postero-lateral protrusion • Results in cord compression rather than nerve root compression (radiculopathy)

Question 51

Thoracic Disc Protrusion: | Clinical Presentation

Answer 51

``` Lower Limb Motor Deficit (61%) – Bilateral 2x more common – Proximal and distal muscles affected – Abdominal muscle weakness – Gait disturbance/paraplegia • Hyper-reflexia/Spasticity (58%) • Bladder dysfunction (24%) • Lower Limb Motor Deficit (61%) – Bilateral 2x more common – Proximal and distal muscles affected – Abdominal muscle weakness – Gait disturbance/paraplegia • Hyper-reflexia/Spasticity (58%) • Bladder dysfunction (24%) ```

Question 52

Low Thoracic Spine - Clinical Patterns

Answer 52

• More common over age 50 ?Associated with degeneration • More common in recreational runners, veteran hockey players – Repetitive loading in extension or semi-flexion • Acute episodes with remission • Localised to one or two T/L segments • Usually unilateral • Referral to lower abdomen, iliac crest, upper buttock, lateral thigh • Shooting pain to anterior hip

Question 53

Complications rib fractures

Answer 53

• Flail segment, pneumothorax, subcutaneous emphysema, haemothorax • Flail Chest: rib fracture in 2 places, moves paradoxically with respiration • Rib fractures are a strong marker of non -accidental injury in children ensure there is adequate explanation for the injury