(7) Functional anatomy, clinical exam, and pathologies of T-spine Flashcards
Why do the thoracic vertebra have extra facets?
Articulations with the ribs
Where do the superior and inferior costal facets articulate with?
The head of the rib
Where do the transverse costal facets articulate with?
The tubercle of the ribs
What joint lies at the superior and inferior costal facet?
costovertebral joint
What joint lies at the transverse costal facet?
costotransverse joint
What is the bony anatomy of the thoracic spine?
- progressively inferiorly angled (most prominent mid-thoracic)
- Generally sp.pro may be as low as facet joint one spinal level below
- Upper/lower T-spine project more horizontally
What are some general guides on the surface anatomy of certain T-spine vertebra?
- T1: 2nd below last moving cervical sp.pro
- T3: in line spine scapula
- T7: in line inferior angle scapula
- T12: in line 12th rib
What is the function of the muscles in the thoracic spine?
- Mobility
- Stability
- Proprioception
Where does the erector spinae travel from?
3 bilateral columns extending from the skull to the sacrum
What are the 3 muscles of the erector spinae?
- spinalis thoracis
- longissimus thoracis
- iliocostalis thoracis
What is the function of the erector spinae?
- extension (bilaterally & concentrically)
- lateral flexion (ipsilaterally & concentrically)
- counter balancing postural disturbances
What joints connect the ribs and the vertebrae?
- costovertebral
- costotransverse
What part of the rib connects to the costovertebral joint?
convex facet on head of rib
What part of the rib connects to the costotransverse joint?
the tubercle of the rib
What is the normative amount of T-spine flexion?
~30-40 degrees in sagittal plane
How does the T-spine move during flexion?
Inf articular facet vertebra slides sup & ant. relative to superior facet below
What is the normative amount of T-spine extension?
~ 20-25 degrees in sagittal plane
How does the T-spine move during extension?
inf. articular facet of vertebra slides inf post. relative to superior facet of vertebra below
What is the normative value for T-spine lateral flexion?
~ 25 degrees in the frontal plane
How does the T-spine move during lateral flexion?
inf articular facet of vertebra slides sup (contralaterally) & inf (ipsilaterally) relative to superior facet of vertebra below
What is the normative value for rotation in the T-spine?
~ 30 degrees in the axial plane
How does the T-spine move during rotation?
inf articular facet of vertebra above slides against sup articular facet of vertebra below
What is included in the clinical interview for T-spine?
- PC
- HPC
- DH
- PMH
- SH
What are some red flags to look out for during a clinical interview of the T-spine?
- Thoracic myelopathy
- Malignancy
- Infection
- Fracture
- Inflammatory
- Deformity
What do you have to be extra cautious of when carrying out a clinical interview with a T-spine patient?
- chest pain
- flank pain
- abdominal pain
- diffuse pain
What does a clinical examination for T-spine normally look like?
- observation
- AROM
- Muscle tests
- palpation
- if upper or lower T-spine pain, may have to clear cervical & lumbar spine
What is looked for during AROM?
- range
- symptom response
- quality
How is a Slump Test carried out?
- patient is asked to sit on edge of bed and slump their back
- flex hip ~90 degrees & extend knee
- chin to chest
- plantar/dorsiflex foot
What does the plantarflexion & dorsiflexion do during the Slump Test?
Dorsiflexing the foot loads the dura, whereas plantarflexing the foot will unload it
What is non-specific thoracic back pain?
- anything that is not serious or radicular
- postural
- mechanical (disc, soft tissue, facet)
How does non-specific thoracic pain present?
- pain
- motion loss
- posture
- muscle involvement
- disability
- impact QOL
What is scoliosis?
- abnormal lateral curvature (+ rotation)
- ‘S’ or ‘C’ shaped
How does scoliosis develop?
- 65% idiopathic (unknown)
- 15% congenital
- 10% neuromuscular disease
How does scoliosis present on examination?
- variable spine pain
- movement restriction
- uneven musculature
- prominent ribs/scapula
- loss of motion
What is the Rx for scoliosis?
- None
- Exercise Rx (Schroth approach)
- bracing
- surgery
What is Scheuermann’s disease?
- Juvenile (hyper-) Kyphosis
- altered vertebral body growth
- anterior wedging (>5 degrees) in 3/more adjacent vertebral bodies
How does Scheuermann’s Disease present?
- prominent curvature (with trunk flexion)
- pain
- rigid kyphosis
What is Hyper kyphosis?
When the Cobb angle is >40 degrees (norm 20-40 degrees)
What is the Rx for Scheuermann’s Disease?
- <60: stretching, mods, NSAIDs
- 60-80: extension bracing
- > 80: surgical opinion
What is the Cobb angle?
- line drawn along superior endplate of most tilted vertebrae on cephalad portion
- line drawn along inferior endplate on most tiled vertebrae on caudal portion
- angle when perpendicular lines cross
How is osteoporosis diagnosed?
DXA scan
How do osteoporotic fractures of the thoracic spine occur?
- spontaneously (cough or twist)
- traumatic (fall)
- single / multiple levels
How does an osteoporotic fracture present?
- variable pain/disability
- older age
- localised tenderness
- kyphotic
What is the Rx for osteoporotic fractures of the thoracic spine?
- analgesia
- rest
- bracing
- +/- physio
- meds to optimize bone health
What is Ankylosing Spondylitis?
- inflammatory back pain
- systemic rheumatic disease
- inflammation on sites where tendons/ligaments insert into bone
How is ankylosing spondylitis diagnosed?
4 out of 5
- onset <40 yoa
- gradual onset
- improved exercise
- not improved with rest
- night pain/waking
What are symptoms of ankylosing spondylitis in the thoracic spine?
- inflammation of whiteness in eyes
- morning stiffness
- imaging
- improved with NSAIDs
How does thoracic disc syndrome occur?
- less common (less mobile)
- lower thoracic
- ~70% asymptomatic
- localised
- +/- radicular
What causes thoracic radiculopathy?
- root impingement/compression
- disc herniation
- metastatic tumour
- scoliosis
- diabetes
What are the symptoms of thoracic radiculopathy?
pain, paraesthesia dermatomal distribution
What is Multiple Myeloma?
cancer of plasma cells in the vertebrae
What are the symptoms of multiple myeloma?
- vague & variable (easy to miss)
- bone pain (lytic bone lesions)
- fatigue
- night sweats
- decrease in appetite
- weight loss
What is spinal tuberculosis?
- ultra rare bacterial infection in intervertebral disc and endplates
What are the risks for developing spinal tuberculosis?
- Exposure (SE asia, India)
- Immunosuppression
What are some symptoms of spinal tuberculosis?
- generally unwell
- weight loss
- loss appetite
- developing kyphosis
- developing spinal cord involvement
