B2. Thoracic Spine Conditions Flashcards
What are the possible thoracic neuro lesions?
- nerve root
- intercostal nerve
- thoracic cord
How common are disc herniations in the thoracic spine?
Rare (0.25-0.75% of all symptomatic spinal disc herniations) and are therefore not in the top 2 causes of neuro lesions in the thoracic spine
What are the top 2 causes of nerve roots and spinal cord damage in the thoracic spine?
Stenosis
Tumor
What are the top 2 causes of intercostal nerve damage?
Trauma
Neuritis
The nipples are the landmark for which NR dermatome?
T4
The diploid process is the landmark for what NR dermatome?
T7
The umbilicus is the landmark for what NR dermatome?
T10
What finding on sensory testing is considered pathognomic for complete cord transection?
- loss of sensation bilaterally below level of lesion
- a horizontal “band” below which no sensation is felt
What is Brown-Sequard syndrome?
Results from injury to one-half of the spinal cord, extending over several spinal cord segments and resulting in flaccid paralysis and cutaneous anesthesia at the level of the lesion while below the lesion there will be contralateral pain and temp loss, ipsilateral spastic paralysis and ipsilateral proprioception, vibration and fine touch loss
What would Beevor’s sign look like for a cord transaction?
Umbilicus deviates upward toward the stronger muscles and away from the paralyzed muscles
What would Beever’s sign look like for nerve root or partial cord injury?
The umbilicus will deviate away from the side of NR damage and toward the stronger muscles
What is a normal and abnormal response to a superficial abdominal reflex test?
Normal: when the skin in each abdominal quadrant is scratched, there is umbilical deviation toward the site of the stimulus
Abnormal: no muscular movement
What would a bilateral loss of abdominal superficial reflex indicate?
Cord transection
NOTE: unilateral would indicated LMNL
Describe the leg pain associated with thoracic myelopathy
It may or may not be present. When it is, it is generalized (non-dermatomal), sometimes in the soles of the feet and described as burning. Back pain is usually worse than leg pain
Describe the leg paresthesia associated with thoracic myelopathy
Sometimes present, non-dermatomal and often described as “numbness”
Describe the SMR findings associated with thoracic myelopathy
May have sensory loss (contralateral pain and temp, ipsilateral proprioception, vibration and 2 point discrimination)
May have UMNL signs such as + Romberg/balance tests, Beevor’s sign and loss of superficial abdominal reflex
What would be the expecting findings of a nerve tension test in thoracic myelopathy?
Negative
What would be expected with spinal loading tests in thoracic myelopathy??
Symptoms unaffected by thoracic load tests
Although rare, when thoracic disc herniation occur, where do they most often occur?
75% are in the lower (T8-T12) thoracics, mostly T11 and T12
What location of thoracic disc herniation may cause spinal cord compression with UMN signs in the lower extremity
Central protrusion
What location of thoracic disc herniation may result in symptoms resembling Brown-Sequard syndrome, with ipsilateral weakness and contralateral pain and temperature disturbance?
Centrolateral protrusion
What location of thoracic disc herniations may cause nerve root compression with symptoms along intercostal spaces?
Lateral
What is a Schmorl’s node?
When an IVD herniated through vertebral end plates into the adjacent vertebral bodies
Are Schmorl’s nodes symptomatic?
Usually not but they can cause an inflammatory/foreign body reaction that causes pain
A return to previous activity level occurs in
approximately what percentage of patients treated for thoracic disc herniations with nonsurgical measures.
80%
When is surgery indicated for thoracic disc herniations?
When myelopathy signs are present
When are thoracic epidural steroid injections indicated for disc herniations?
For patients who have unacceptable levels of pain that has not responded to other conservative treatments
What is intercostal neuralgia?
Irritation or pinching of spinal nerves at spinal canal or intercostal nerve around the ribs that causes severe pain
What are some possible causes of neuralgia in the thoracic spine?
- injured chest or ribs
- entrapment of intercostal nerves
- degeneration of intercostal nerves
- pregnancy that expands the rib cage
- rib infection or osteomyelitis
- surgical procedure in area
- tumors
- post infection (post herpetic neuralgia)
Inflammation of a nerve
Neuritis
Traumatic strains in the thoracic spine are rare but if they occur, most commonly involve what muscles?
Middle and upper trap
NOTE; usually associated with unilateral lifting
Traumatic sprains in the thoracic spine are rare but if they occur, commonly involve what structures?
the rib cage (costovertebral, costotransverse and anterior costal cartilages)
Intercostal muscle strains can have what neurological complication?
Intercostal neuritis
Pain associated with costovertebral joint sprains may be significantly aggravated by what?
Breathing/coughing
NOTE; DDX is fracture because these will also be painful with fracture
What are three injuries that can happen to ribs?
Sprain
Fracture
Joint dysfunction
Describe the pain associated with rib fracture
- aggravated by inspiration/coughing
- aggravated by palpation, tuning fork or percussion
What are the ancillary studies for rib fracture?
AP and lateral radiographs and possibly CT if needed
What is the chance that a rib fracture is present but not seen on radiographs?
50/50
No-displaced fracture may not show up on X-ray for how long?
3 weeks
What should be done next, if there are equivocal findings on initial x-ray when rib fracture is suspected?
- CT or
- Follow up/repeat in 3 weeks
What are some complications that can occur with a displaced rib fracture?
Damage or lungs, kidneys. Spleen or liver
What additional test would you do with a rib fracture if you suspect lung complications?
Auscultatory
What additional tests would you do with a rib fracture if you suspect kidney complications?
UA for blood
What additional tests should be done with a rib fracture if you suspect spleen/liver complications?
- palpate abdomen
- take BP
What is the management plan for rib fractures?
- pain control to avoid pneumonia from splinting
- incentive spirometry to aid in prevention of atelectasis
- clutch pillow to protect ribs while coughing or sneezing
- rib belts/binders can be used in subacute phase but increase risk for atelectasis and pneumonia
Most rib fracture heal within what time period?
6 weeks
Describe the pain associated with rib sprain and joint dysfunction
- often sharp with point sensitivity
- aggravated by breathing
How is rib joint dysfunction treated?
Manipulation although effective can be painful
How are rib sprains treated?
K-tape (not bracing)
What are the three medical interventions for thoracic facet joint syndrome?
- medial branch block
- radiofrequency neurotomy of medial branch
- intra-articular steroid injection
Among patients with upper or mid back pain, what percentage have thoracic facet joint pain?
34-48%
What are three common referral patterns for thoracic IVD syndrome?
- retrogastric (mimics cholecystitis or nephrolithiasis)
- restrosternal (mimics MI)
- inguinal (mimics hernia)
How do referral patterns vary with tear location in thoracic IVD syndrome?
- anterior tears can refer pain to anterior extraspinal sites such as ribs, sternum and chest wall
- lateral tears can refer pain to visceral or musculoskeletal sites
- posterior tears produce local or diffuse back pain
What are some examples of postural and repetitive stress injuries of the thoracic spine?
- scapulocostal syndromes
- snapping scapula
- thoracic/rib joint dysfunction
- postural sprain syndrome
- intercostal/scapular MFTPs
- facet syndrome
- disc derangement
What are common habitual postures that can lead to postural sprain/strain?
- forward head carriage
- protracted shoulders
- slumping
Postural sprain/strain are associated with increased kyphosis due to:
- rounded shoulders
- Upper cross syndrome
- large breasts
- tall individuals
- structural hyperkyphosis (Scheuermann’s compression fractures)
What muscles are weak in upper cross syndrome?
- deep neck flexors
- lower trap
- serratus anterior
What muscles are tight in upper cross syndrome?
- pectorals
- upper trap
- levator scapula
What is a scapulocostal syndrome?
A myofascial syndrome from traumatic or mechanical irritation of the soft tissue in the scapulocostal interspace (between the scapula and rib cage)
How does scapulocostal syndrome present?
- pain along vertebral border and deep to scapula that can refer to posterior shoulder and arm
- abnormal sensations (dysesthesia) in the arm and forearm
- painful and decreased shoulder abduction
- MFTP and tenderness along the vertebral border of the scapula
A scapular syndrome, AKA sick scapula has what 4 findings?
- Scapular malposition (forward tilt, protraction, inferior)
- Inferior/medial border winging (from weak serratus anterior and/or middle trap and right pecs)
- Coracoid tenderness (from tight pec minor)
- dysKinesis
What is washboard syndrome AKA snapping scapula?
A scapulocostal syndrome where crepitus, bursitis and scapular dyskinesis is caused by bony and/or soft tissue abnormality in scapulocostal space
What are the 2 most common components of T4 syndrome and what is a third symptom that sometimes accompanies it?
- T4 joint dysfunction
- glove paresthesia
- sometimes headache with helmet distribution
- sometimes associated with cardiac symptoms instead of glove paresthesia or headache
DIagnosis of T4 syndrome is made after excluding what three things?
- TOS
- carpal tunnel
- cervical radiculopathy
Symptoms of T4 syndrome may be mediated by what?
Sympathies nervous system
What are some of the thoracic spine findings that may be present with T4 syndrome?
- hypermobile upper thoracic segment
- rib angle palpation may be tender
- forward head carriage
- flat thoracic spine
- interscapular pain/stiffness
- cervical and trunk AROM is painfree
How does the pain and paresthesia distribution differ in T4 syndrome?
Paresthesia is in a glove like distribution while the pain is more generalized in arms and forearms
What phenomenon can also be seen with T4 syndrome, suggesting ANS involvement?
Raynauds
What would the expected results of SMR testing in T4 syndrome be?
Normal
Who gets T4 syndrome?
- 30-50 year olds
- women>men 4:1
- activities requiring frequent stooping or bending
The exact mechanism of T4 syndrome is unclear but it is hypothesized that:
sustained or extreme postures lead to relative ischemia within multiple tissues contributing to symptoms of sympathetic origin
What is another name for T4 syndrome?
Upper thoracic syndrome, because symptoms may not be derived solely fro T4 but also other upper thoracic vertebra
What is the management plan for T4 syndrome?
- explain to patient
- CMT
- STM
- home exercises for self- mobilization of joints in upper thoracic, postural exercises, strengthening of scapulothoracic muscles, stretching tight pecs
- eliminate aggravating activity/behavior
What is Raynaud’s phenomenon?
A vascular constrictive disease of the distal extremities where vasoconstriction is provoked by cold or emotion stress. It causes sequential discoloration (white -> blue -> red) of digits, numbness, tingling, swelling and pain. Last minutes to hours
Who gets Raynaud’s?
- Women>men 9:1
- onset with menarche is common
- migraineurs
What is the most common type of Raynauds?
Primary
What is the cause of primary Raynauds?
Unknown etiology (no associated disease or condition)
Which type of Raynauds is more benign?
Primary
Secondary Raynauds is associating with what diseases?
- Connective tissue diseases, such as scleroderma
- autoimmune disease such as Sjogrens, lupus, RA
- trauma
What are some serious sequels that can occur with advanced stages of secondary Raynauds?
- trophic changes
- skin ulcers
- gangrene
What are some risk factors that may be associated with secondary Raynauds?
- HTN meds
- narcotics
- prolonged vibration (jackhammer)
What is the treatment for Raynauds?
- stress management
- smoking cessation
- avoiding cold and other triggers
- chiro
- heat/paraffin soak
- circumduction movements
- nutrition
- treat associated disease
- possible digital sympathectomy
