Conditions of the Thoracic Spine Flashcards
Postural Dysfunction/Syndrome
Definition:
A condition that is usually due to poor posture, where normal spine curvature can become excessive and thus increase gravitational stress and cause undue wear and tear on joints. This causes pain in the lumbar and cervical regions. Even in the hips and legs can be involved.
Differential Diagnosis:
Headache (cluster, migraine, tension)
Spinal Deformaties (Structural)
Neoplastic, Traumatic
Osteochondrodystrophies (A disease of bone and cartilage)
Types of Postural Dysfunction 2
Lordosis (Increased/Absent)
Kyphosis (Increased/Absent)
Postural Syndrome - Excessive Lordosis
Presentation/Causes
postural or functional deformity
lax muscles, especially abdominal muscles in combination with tight muscles such as hip flexors
heavy abdomen, weight gain
pregnancy (Normal and only during pregnancy)
compensation from another deformity such as kyphosis
spondylolisthesis
congenital problems, such as bilateral congenital hip dislocation
failure of bone formation
Excessive Lordosis
2 Main Types
Pathological lordosis
Excessive lumbar lordosis
Sagging shoulders, medial rotation of arms if compensatory increase in kyphosis
Head pokes forward
Increased pelvic angle to 40 degrees (normal is 30)
Mobile spine and anterior pelvic tilt
Tight hip flexors and TFL, with WEAK abdominal
Sway Back
has pelvic in neutral or posterior tilt
increase in kyphosis at lumothoracic junction
increase at lumbosacral angle such that the entire pelvis shifts anteriorly
Changes associated with pathological lordosis
Changes associated with swayback
Postural Syndrome - Excessive/Decreased Kyphosis
Sheuermann’s disease
usually occurs in adolescence and causes vertebrae to take on a wedge shape rather than cylindrical affects approx 10% of the population usually between T10 an L2 Round back long rounded curve with decreased pelvic inclination (less than 30 degrees) trunk is often flexed forward with a decreased lumbar lordosis tight hip extensors, tight trunk flexors, weak hip flexors and lumbar extensors
Humpback (Gibbus deformity)
Localized, sharp posterior angulation in the thoracic spine Usually a sharp angulation of the spine at a single vertebral level commonly a structural deformity as the result of a fracture or pathology
Flat back
Pathological reduction in the normal kyphosis is unusual. May be observed after surgery to correct thoracic scoliosis
Dowager’s hump
Often in older patients
Caused by osteoporosis
Thoracic vertebral bodies degenerate and wedge anteriorly
Congenital kyphosis
Curvature present at birth.
Vertebral bodies are triangular and often fuse anteriorly
Postural Dysfunction/Syndrome special tests
Special Tests:
No Special Tests Here
Simple Observation/History of posture that was discussed last lecture
Postural Assessment Checklist
Rib Subluxation/Slipping Rib Syndrome
When abnormal movement of a rib, usually a false rib, occurs due to an unstable cartilaginous attachment. This can cause impingement of an intercostal nerve
It can also be known as:
Clicking Rib
Displaced Rib
Painful Rib Syndrome
Characteristics/Symptoms
Pain in the lower chest (minor to moderate)
Pain in the upper abdominal region
Flank Pain
Pain usually preceded by an activity such as sitting and leaning forward
Intermittent sharp stabbing pain then followed by constant dull pain that can last for hours to weeks
Worsened with certain movements (Lifting, Bending, etc)
Can also cause visceral pain due to location of nerves
Special Tests:
Hooking Manoeuvre (Not taught in this class)
Other Investigations
Palpation where tenderness is felt above the costal margin or a painful click is sometimes felt over the tip of costal cartilage involved
History of recent trauma or certain postures.
SCOLIOSIS
Definition:
A lateral CURVATURE of the spine within the vertebral column
Labelled as C-Curves(1 curve) or S-curves(2 curves)
Described according to the side of the CONVEXITY
Primary Curvature is where the Vertebrae become misaligned
Secondary Curvature is where above and below the curve tries to compensate to maintain normal head and pelvis position
To measure the curve in degrees of the spine, “The Cobb angle” is used. Typically, a Cobb angle of 10 Degrees is regarded as a minimum angulation to define scoliosis.
Can be FUNCTIONAL or STRUCTURAL
Differential Diagnosis:
More frequent in XX vs XY
Idiopathic is MC (90%) but can be Congenital (Vertebrae fail to form properly)
Neuromuscular: UMN or LMN Lesion
Postural: Leg Length, Muscle Imbalances/Spasm
Neoplastic, Traumatic
Osteochondrodystrophies (A disease of bone and cartilage)
History:
Back Pain (Upper, Mid, and Lower)
Trouble Breathing (If curvature is really bad)
Muscle Fatigue
Weakness/Numbness down lower body (If nerves are involved)
Trouble finding comfortable sitting /laying positions
Headaches (possibly)
Physical:
Back Pain due to Curvature
Visible or Palpable Curvatures
Asymmetry with shoulder height when bent forward
Leg Length Discrepancy
Scapulae are more visible, Flank Crease due to side bending, and an Asymmetric Pelvis
Special Tests:
Adam’s Sign (Test)
(+) Structural when Bending makes curve more obvious
(+) Functional, when Bending makes curve go away
Other Investigations
X-Ray is Best to measure Cobb Angle
Treatment
Depends on Cobb Angle
<25 Degrees, Observe only
>25 Degrees, Bracing (many types) also controversial
>45 Degrees, Surgical Correction (Rods or Spinal Fusion) Due to possible respiratory problems and cosmetically unacceptable
Structural vs Functional
Structural Curves
Fixed due to bony changed
Wedge vertebrae
Hemivertebra
Resulting in: Asymmetric side bending
May be progressive
Curve does not disappear on forward flexion
Cannot be corrected without SURGERY or BRACING (Harrington Rods)
Functional Curves
Not fixed and mainly due to posture/muscle imbalances
Can be corrected with voluntary effort
Caused by:
Postural problems
Nerve root irritation
Compensated leg length discrepancy
Resulting in: Symmetric side bending
Not progressive
Curve disappears on forward flexion
Thoracic Outlet Syndrome
Definition:
A Collection of syndromes that cause compression of the neurovascular bundle
Brachial plexus
C8 and T1 nerve roots
Subclavian artery
The BRACHIAL plexus and its accompanying artery can be compressed:
Between the Anterior and Middle Scalenes
Between the Coracoid Process and Pectoralis Minor
Between the Clavicle and the First Rib
Compression causes Neuropraxia (Loss of nerve conduction)
Differential Diagnosis:
Acromioclavicular Joint Injury
Cervical Disc Injuries
Cervical Radiculopathy
Clavicle Fractures
Elbow and Forearm Overuse Injuries
Shoulder Impingement Syndrome
Thoracic Disc Injuries
Tight anterior and/or middle scalene
Tight pectoralis minor musculature
Approximation between clavicle and 1st rib
Contusions due to trauma
Clavicular fractures from trauma
Whiplash from trauma
Internal (Bony Callus or Cervical Rib)
External Compression (Crutches)
Poor Posture or Prolonged Poor Positioning
Trauma or Joint Subluxation
Systemic or Metabolic Disorders (RA, DM, etc)
Pregnancy (Fluid retention and postural changes)
Vascular Symtoms
Swelling and puffiness in the arm/hand
Bluish discolouration of the hand
Feeling of heaviness in the arm/hand
Pulsating lump over the clavicle
Deep, boring toothache-like pain in the neck and shoulder region, that increases at night
Superficial vein distention in the hand
Neurological Symtoms
Paresthesia along the inside forearm and palm
Muscle weakness and atrophy of gripping muscles and small muscles of the hand
Difficulty with fine motor tasks of the hand
Cramps of the muscles of the inner forearm
Pain in the arm and hand
Tingling and numbness in the neck, shoulder region, arm, and hand
Thoracic Outlet Syndrome Special Tests
Special Tests:
Roos Test (General compression test)
(+) pain, heaviness, or profound arm weakness or numbness and tingling of the hand
Costoclavicular Test (Compression by the 1st rib and the clavicle)
(+) disappearance or diminution of the pulse, or if symptoms are elicited
Wright’s Hyperabduction Test (Compression behind the pec minor muscle and under the coracoid process)
(+) disappearance or diminution of the pulse, or if symptoms are elicited
Adson’s Test (Compression due to tight scalene muscles)
(+) disappearance or diminution of the pulse, or if symptoms are elicited
Compression fracture
Definition:
A fracture or break in bone that is due compressive forces
This usually occurs in the vertebrae and at the front of them
Eventually causing the body to lean forward
Causes
Osteoporosis
Compression type injury
Tumours (Due to bone weakening)
Back pain that is slowly worsening over weeks or months
Standing making the pain worse vs laying down making it better
Decrease in height
Stooped over posture
Other issues that may arise due to nerve damage from the fracture:
Weak muscles
Problems walking
Bladder or bowel issues
Numbness or tingling
Compression Fracture Special Tests
No special tests
More of a history taking rule in/out type of pathology
Postural assessment and gait
Need imaging (X-Ray)
If suspecting a compression fracture, then refer to doctor to refer to imaging
Scheuermanns Disease
Definition:
A pathological condition that may result in structural hyper-kyphosis
Inflammation of the bone and cartilage occurs around the ring epiphysis of the vertebral body
Often leads to anterior wedging of the vertebra
A growth disorder usually diagnosed around 12-17 years of age, that affects around 10% of the population
Most cases, several vertebrae are affected (T10-L2) is most common
Differential Diagnosis:
Functional Kyphosis
Flat Back
Hump Back
Round Back
Dowager’s Hump
Causes:
Unclear
They believe that their is a hereditary component
Characteristics/Symptoms
Exaggerated Kyphosis
Age 12-17 around
Pain in the back (Upper, Middle, and Lower)
Blood work showing inflammatory markers raised
Special Tests:
No special tests
More of a history taking rule in/out type of pathology
Postural assessment and gait
Need imaging (X-Ray)
If suspecting a compression fracture, then refer to doctor to refer to imaging
Blood work would also help
Vertebral Subluxation
Definition:
The alteration of the normal dynamic, anatomic, or physiologic relationships of contiguous (touching) articular structures. A motion segment in which alignment, movement integrity, or physiologic function is altered, although the contact between the joint surfaces remains intact.
NOT A DISLOCATION
Tight muscles that connect with the vertebrae (Mulifidis, Erectors, etc)
An injury
Chronic Compensation due to pain or injury
Characteristics/Symptoms
Pain in the vertebral area
Decrease AROM
Possible muscle weakness or compensation
Vertebral Subluxation symptoms
Special Tests:
No special tests really
More assessment of AROM, posture and gait
A different type of assessment (Spinal Functional Movement Assessment)
Thoracic ROM
AROM:
Flexion = 20 - 45 degrees
Patient Seated or standing
Have them reach for their toes
Extension = 25 - 45 degrees
Patient seated or standing
Place hand at small of back to add stability
Extension should be straight and even with no side bending or rotation
Side bending = 20 - 40 degrees
Patient standing will slide hand down side of the leg
Patient seated will laterally bend
Rotation = 35 - 50 degrees
Seated to avoid hip movement
cross arms over shoulders and rotate
Passive ROM
Patient seated
Examiner applies an over pressure to the end of each active ROM to assess end feel
Resisted ROM
Patients is seated and in neutral
Examiner resists all of the thoracic spine AROM
Assess for weakness
SOL=space occupying lesion
Correct posture
The position of minimal stress to each joint
Minimal muscle activity is needed to maintain posture
Faulty posture
Any position that increases the stress to the joints
If muscles are weak or shortened, or joints are stiff or too mobile, the posture cannot be easily altered to the correct alignment, this can then result in pathology
Pathologies arise from both repeated small stresses over a long time or constant abnormal stresses over a short time
Leads to excessive wearing of articular joint surfaces, osteophytes, and weakened, stretched, or traumatized soft tissue
Anatomic factors contributing to posture
Laxity of ligaments
Fascial and musculotendonous tightness
Muscle tone
Joint position and mobility
Neurogenic factors
Postural factors contributing to posture
Poor postural habit
Muscle contracture
Pain
Respiratory conditions
Structural factors contributing to posture
Result from congenital anomalies, developmental problems, trauma, disease
Bony contours
Anatomical leg length discrepancy
Behavior and affect contributing to posture
Note the patients attitude, if the patient is tense, bored or lethargic
Does the patient appear to be healthy, emaciated or over weight? answers may indicate how much is needed to be done
if the patient is lethargic it may take longer to correct problems (is the patient truly interested in correcting posture)
a persons posture in many ways is an expression of one’s personality, sense of well being and self esteem
