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PHTY301 > 11 (a) Thoracic Spine: Pathology and Clinical Presentation > Flashcards

11 (a) Thoracic Spine: Pathology and Clinical Presentation Flashcards

1
Q

• Costovertebral joints

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

Main ligament Costovertebral joints

A

• Main ligament –radiate ligament

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3
Q

Costotransverse Joints

A
  • Synovial joints between ribs and transverse processes

* None for ribs 11 and 12

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4
Q

Supporting ligaments Costotransverse Joints

A
  • Supporting ligaments:
  • Superior CT lig
  • CT lig
  • Lateral CT lig
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5
Q

Zygaophyseal Joints

• T1

A

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

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6
Q

Zygaophyseal Joints • T 2- T 11-

A

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

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7
Q

Zygaophyseal Joints • T11 and 12

A

• T11 and 12 – transitional with lumbar spine

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8
Q

• Ligaments Zygaophyseal Joints

A

Ligaments – lig flavum, posterior longitudinal, interspinous,etc

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9
Q

Spinous Processes Angle of projection

A

Angle of projection has implications for thoracic palpation asst
and Rx

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10
Q

Spinous Processes

• Angle of projection T 1-3,12

A

• T 1-3,12 – project directly posteriorly

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11
Q

Spinous Processes

• Angle of projection T4-6,11

A

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

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12
Q

Spinous Processes

• Angle of projection T7-9

A

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

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13
Q

Rib Movement With inspiration

A

• With inspiration ribs pulled up and forward

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14
Q

• Ribs 1-6

A

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

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15
Q

Ribs 7-10

A

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

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16
Q

How do ribs change with age?

A

• Ribs are elastic in children but become increasingly brittle

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17
Q

Mobility of the thoracic spine

A
  • Major function is rotational mobility

* Sagittal movement relatively limited

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18
Q

How is sagittal movement limited in Tx spine?

A

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

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19
Q

Normal thoracic curce

A

Normal curve 20- 50 degrees

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20
Q

Exaggerated thoracic curve -

A

Dowager’s Hump /Kyphosis

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21
Q

What is Scheuermann’s Disease

A

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

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22
Q

What vertebrae are most commonly affected in Scheuermann’s Disease

A

• 7th and 10th vertebrae most commonly

affected

23
Q

Lower and upper thoracic curve Scheuermann’s Disease

A

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

24
Q

What is scoliosis

A

• One or more lateral curves thoracic /lumbar spine

25
Q

Non-structural scoliosis

A

• Non-structural from poor posture, nerve root irritation,

hysteria, limb length discrepancy, hip contracture

26
Q

Structural scoliosis

A

Structural – genetic, idiopathic, congenital problem (wedge

vertebra)

27
Q

In which direction do vertebral bodies rotate in scoliosis

A

Vertebral bodies rotate to the convexity - pushes ribs

posteriorly

28
Q

Indication surgical treatment for scoliosis

A

• 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.

29
Q

Hx: young (13-16) thoracic presentation

A

Scheuermann’s Disease /scoliosis (female)

30
Q

Hx: older thoracic presentation

A

• Older – osteoarthritis /osteoporosis

31
Q

Pain around chest Tx spine?

A

Costovertebral

32
Q

Pain with digestion Tx spine?

A

Viscera

33
Q

Tx spine - skin symptoms

A

shingles

34
Q

Patterns of Mechanical Thoracic Pain

A
  • 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
35
Q

Non-mechanical Causes of Thoracic Spine

Pain

A 
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
36
Q

Visceral Structures Referring

A

• 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

37
Q

Indicators of Serious Pathology

(Thoracic ‘Red Flags’) Tx Spine

A
  • 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
38
Q

Cervico-thoracic Postural Pain

A 
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
39
Q

Thoracic Outlet Syndrome

A

• 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

40
Q

13
Thoracic Outlet Syndrome
Clinical Features

A 
• 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
41
Q

T4 Syndrome

A

• 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

42
Q

Mid thoracic Instability

A

• 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

43
Q

Instability at CT /CVJ’s Tx Spine

A

• 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)

44
Q

Acute ‘locked’ thoracic joint

A 
• 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:
45
Q

Mid-thoracic hypo-mobility disorders

A

• 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)

46
Q

Mid-thoracic hypo-mobility disorders aggravating factors

A

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

47
Q

Mid-thoracic hypo-mobility disorders Movement Impairments

A

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

48
Q

Early Symptoms of Ankylosing Spondylitis

A

• 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)

49
Q

Ankylosing Spondylitis

A 
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
50
Q

Thoracic Disc Protrusion

A

• 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)

51
Q

Thoracic Disc Protrusion:

Clinical Presentation

A 
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%)
52
Q

Low Thoracic Spine - Clinical Patterns

A

• 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

53
Q

Complications rib fractures

A

• 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

PHTY301 (9 decks)

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