Clinical Conditions Flashcards
osteoporosis
vertebral bodies, lose bone trabeculae
loss of transverse trabeculae lead to collapse of loadbearing beams
end plates collapse leads to end plate concavity
Increase kyphosis and loss of stature with aging
fused mid thoracic vertebrae
Results results from diffuse idiopathic spondylitic hyperostis DISH
Or ankylosing spondylitis
hypomobility
localized posterior slightly off the midline towards one side
Suggesting costotransverse joint
One side radiates slightly a few inches
Chest wall pain common
Costochondral region
Low back pain as a referral from the TL junction
Traumatic thoracic injuries
In flexion or axial compression vertebrae or more injured more often than the discs
In the upper thoracic spine extension causes more injury with thoracic facet injuries, almost as common as cervical facet injuries
traumatic injuries in order of severity, least to most
endplate fracture
bone bruise
Wedge compression
Burst fracture
disc injuries versus vertebral body injuries prevalence
Disc injuries predominate in cervical spine
vertebral body injuries predominate in thoracic spine
what are the most regularly injured segments?
T12 and L1
Flexion compression trauma
affect the anterior elements
end plate fracture
Bone bruising
Wedge compression fracture
Burst fracture
Disk disruption
highest level was for compression fractures
T 11
T12
L 1
kyphoplasty cannot correct
An established deformity of the spine and certain patients with osteoporosis are not candidates for the treatment
Who are likely candidates for kyphoplasty?
patient experiencing painful symptoms or spinal deformities from recent osteoporotic compression fractures
Within an eight weeks of the fracture
Changes in height and spinal alignment can lead to
chronic or severe pain
Limited function and reduce mobility
Loss of independence in daily activities
Decreased lung capacity
Difficulty sleeping
Greatest percentage of patients presenting with thoracic pain will
Have been involved in any trivial accident, such as a fall, someone bumping into the rib cage or prolonged loading
thoracic disc lesions
Attachment of ribs to annulus fibers may be one reason for higher incidence
Blow to rib may affect or disrupt the disc
other reasons
Higher viscosity of IVD
Asymmetrical loading-
most affected area for thoracic disc lesions
Lower thoracic spine
Thoracolumbar junction
common on convex side of a scoliosis or kyphosis
Due to asymmetrical loading
thoracic radiculopathy
mechanical pressure on a healthy nerve root results in numbness, weakness and paresthesia, not pain
local ischemia may occur for local discomfort
nerve root pain is either mechanical compression or chemical irritation
Mechanical- local discomfort with numbness and paresthesia
Chemical - severe pain distal is greater than proximal
may occur due to
Disc lesions
Facet injury or swelling
Osteophytes
Scarring
True nerve root pain, distal pain will be
Distal pain( anterior next to sternum) will be greater than proximal pain(back)
Costochondritis may closely simulate
Thoracic nerve roots symptoms because the pain is also located anteriorly at the sternum
upper thoracic spine will refer symptoms into
The upper extremities
facet joint injuries are common in
both regions
Cervical and thoracic spine
facet joint dysfunction
Usually produce localized sharp pain unilaterally
For chronic stage, it may be dull and achy
Pain more likely to be aggravated by compressing or closing down facet joints extension
Pain may be Referred into nerve root distribution, but no neurological symptoms
referred pain will be more intense proximally versus distally
ligamentous injuries
Pain in the thoracic spine can be from highly ligamentous reinforced joints
Small ligaments-sprain
Any force applied to the rib cage can affect ligaments
Ligaments stabilize and play important role in proprioception
Pain from ligamentous structures
described as vague, ill defined
Spread around the area
Not producing symptoms, distillate, nor producing neurological symptoms
Both ALL and PLL innervated by sinovertebral nerve
will cause pain that spread up and down the spinal canal
rib cage injuries
Breathing may increase pain
area very tender palpation
acute
-Hematoma may be present
-tap test with reflex hammer or vibration
chronic
-Old slow, healing rib fractures may become a chronic source of discomfort
Muscle injuries
True muscle injuries of the spine are very uncommon
musculoskeletal system does get affected through joint injuries and postural changes
Muscle spasms are very common in upper thoracic spine especially around the scapula
T4 syndrome
etiology unknown
Maybe an autonomic syndrome or mechanical problem involving facet joints
Glove Syndrome because of dull aching symptoms covering whole hand, non-dermatome and with or without pins and needles
Symptoms usually unilateral
cervical uncovertebral joint symptoms
very little pain, vague discomfort
stiffness is greater problem than pain
no Referred or neurological symptoms
Morning Stiffness
posterior primary rami innervate
Skin on the back between angles of the ribs
Can mimic trigger points when traveling through the muscles
common red flags
unaffected by spinal movement
Associated symptoms like heartburn
Past medical history
Insidious onset of symptoms
Age under 20 or over 50
Family history
Past personal history
Sudden, unexpected weight loss or gain
Cardiac pain
pain for myocardium
from decreased blood flow buildup of metabolites and ischemic segment of the heart
Characterized as squeezing substernal sensation tightness, or pressure
Usually in the morning or end of the day
acute myocardial infarction
Intolerable, gripping or crushing sensation under their sternum
Diaphoresis and shortness of breath
angina pectoris
Increased pain with exertion
Regardless of location, pain is always worsen with exertion and relieved with rest
aortic dissection
Marked distention of aortic adventitial coat which contain high concentration of nociceptive fibers
pain is sudden and rapidly becomes severe
paint is unrelenting and not changed by position
Patient appears in distress and may be pale or cyanotic
Blood pressure is often normal, but distal pulses are frequently decreased or absent
Pericarditis
inflammation of the pericardium
Secondary to
Infection- bacteria, viral or fungal
systemic disease - rheumatoid arthritis, connective, tissue diseases or uremia
Metastatic tumors
Drugs - procainamide, hydralazine, phenytoin, anticoagulants
Idiopathic
Pericarditis symptoms
mild to severe chest pain that is aggravated by respiration cough or thoracic motion
Pain may be relieved with sitting and forward bending
Fever, chills and weakness are common
Tachycardia and cough are variable
pericarditis pain pattern
Within epigastrium and left parasternal region
If the diaphragm is irritated, pain is referred to the left trapezius
Patient with acute symptoms should be transferred immediately to an ER
mitral valve prolapse
Results from thickened leaflets that are large and redundant
Effect 4 to 7% of population
More common in women than men
Chest pain reported 40 to 50% of affected patients
Pain is characteristically, sharp or sticking in nature
Some may report dull pain
Agina like symptoms for mitral valve prolapse
10 to 20% of affected patients
stethoscope
Mid systolic non-ejection click and late holosystolic murmur
Pain generally non-exertional and momentarily but occasionally lingers minutes to hours
mitral valve prolapse frequency and location
More frequent during periods of emotional stress
Typically
Retro sternal
Left sided chest
Not referred to distal sites
esophageal disorders
Irritation from foreign bodies or tumors, erosion from acid reflux and motility problems
Gastro esophageal reflux leads to a mild severe burning sensation in the epigastric to retro sternal area
Pain often worse at night because of a supine position allows reflux of stomach acid into the esophagus
Patient may complain of brackish taste, and frequent belching
tracheobronchial pain
Pain from inflammation of the tracheobronchial tree characteristically is referred to the upper portion of the sternum and lateral to the sternum at points corresponding to the major bronchi
Pleurisy
parietal pleural contains pain fibers that are conveyed through the chest wall through the intercostal nerves
Irritation of the pleura, thereby results in chest wall pain
widening Of the intercostal space during inspiration stretches, the inflame parietal pleural and accentuates the pain
Pleural inflammation, may be caused by
Underlying lung insult from pneumonia or pulmonary infarction
Direct entry of infection to the pleural space empyema
Hematological or lymphatic spread - TB, uremia, cancer, collagen, vascular disease
Pleural trauma like rib fracture
pleurisy pain pattern
over side of pleurisy or the chest wall
Central diaphragm is irritated Pain may be referred to the neck and shoulder.
pulmonary embolism
Caused by a sudden lodging of a blood clot in the pulmonary vascular tree with resultant obstruction of blood flow
Complete obstruction - pulmonary infarction, which may lead to a consolidation necrosis of lung tissue
Medical emergency
Thrombus formation usually occurs at a distance site like the venous system of the leg or subclavian vein in the arm
Predisposing factors of pulmonary embolism
recent surgery less than one month
Trauma
Immobilization
Cancer
Pregnancy
Oral contraceptive use
Obesity
Advanced age
pulmonary embolism pain
usually Secondary to pleurisy from a peripheral infarction
same pain pattern
Dyspnea
hemoptysis
tachypnea
Thoracic pain referred from abdominal
Generally transmitted through T6 to T 12
Some structures in the chest are innervated as low as T9
cholecystitis
inflamed gallbladder
Typically occur one to two hours after a heavy meal
Sudden or gradual onset of severe pain which peaks after 2 to 3 hours and resolves in approximately 10 hours
Passing gallstones gives the sudden intense proximal pain of biliary colic pain is characteristically located in the right upper quadrant of the abdomen the right subscapular area or both
acute cholecystitis
Fever
Chills
Moderate to severe distress
Tenderness could be elicited in the right upper quadrant that verses on deep inspiration aka Murphy sign
peptic ulcer disease
Increase production of gastric acid or decreased cytoprotection of the stomach lining from chronic NSAID use leads to erosion of the gastric mucosa
Pain originating from the stomach transmitted through the seventh through ninth thoracic nerve roots
peptic ulcer disease pain
Burning
felt in epigastrium below the xiphoid process or left upper quadrant of the abdomen
significant erosion may cause patient to complain of boring sensation through the back
Burning pain typically begins when two hours after a meal and could be temporarily relieved with antacids
Perforation of the stomach wall lead to free air accumulation under the diaphragm and causes referred pain to the shoulder
renal disease
Pain originating from the genitourinary system involves the thorax only at the costovertebral angle
Pain could be result of either renal inflammation (pyelonephritis) or distention (sudden obstruction)
Patient with acute pyelonephritis generally will have signs of urinary tract infection, which will proceed the development of flank pain
renal disease symptoms
Fever, chills, sweats, and tenderness can be elicited by percussing the costovertebral angle
no change of position relieves the pain
