T-Spine Common Clinical Presentation

Question 1

List some common clinical presentations of T-Spine

Answer 1

1. Pancoast Tumor
2. Fracture
3. Scheurmann’s Disease
4. Costochondritis
5. Disc disease
6. Thoracic Myelopathy
7. T4 syndrome
8. Scoliosis
9. Arthropathy
10. Rib dysfunction
11. Thoracic Outlet Syndrome (TOS)

Question 2

what is a Pancoast tumor?

Answer 2

a tumor at the apex of the lungs

may involve C8 and first thoracic nerve structures

may present similiar to MSK origin (especially TOS)

Question 3

list the s/s of a Pancoast tumor

Answer 3

1. chronic cough
2. bloody sputum
3. unexplained weight loss
4. malaise
5. dyspnea

Question 4

describe the physcial examination findings for Pancoast tumors

Answer 4

1. fever
2. wheezing

Question 5

what types of disorders can have referral patterns around the T-Spine?

Answer 5

1. MI
2. Pericarditis
3. Pneumothorax
4. Pleuritis
5. Pleuropulmonary disorders

Question 6

what portion of the vertebrae are fractures most common in the T-Spine?

Answer 6

posterior component fractures

Question 7

what 3 components describe the risk/need for surgery related to vertebral fracture?

Answer 7

1. morphology
2. integrity of PLC
3. Neurologic status

Question 8

vertebral fractures can be classified into what categories based on morphology?

Answer 8

1. Compression
2. translation/rotation
3. distraction

Question 9

compression fractures can be subclassified into what 2 categories?

Answer 9

1. traditional compression fractures
2. burst fractures

Question 10

describe traditional compression fractures

Answer 10

stable injury

anterior column solely affected

spinal canal intact

common mechanism axial loading in flexed position

traumatic: high energy and osteoporotic

Question 11

describe burst fractures

Answer 11

impacts anterior and middle columns

most common at TLJ

potential neural involvement; fragments may be found in canal

vertebral segment subjected to high force axial (and/or flexion load)

Question 12

describe rotational/translation fractures

Answer 12

associated with fall from a height or heavy object falling on body with bent trunk

torsion and shear forces

horizontal displacement of one T/L vertebral body on another

dislocation: facet joints intact, but dislocated

Question 13

describe distraction fractures

Answer 13

• separation in the vertical axis
• impacts:
  
  • anterior and posterior ligaments
  • anterior and posterior bony structures
  • all of the above
• potential frx to posterior elements
• must do neuro testing in this population

Question 14

list red flags for vertebral fractures

Answer 14

1. Older age
2. significant trauma
3. corticosteroid use
4. contusion/abrasion

Question 15

name 2 clusters that can be used to detect a vertebral fracture

Answer 15

Roman (better in osteoporotic fractures)

Henschke (more concerning for traumatic type injuries)

Question 16

list the factors on Henschke’s cluster

Answer 16

1. Age > 70 yrs
2. significant trauma
3. prolonged corticosteroid use
4. sensory alterations from the trunk down

Question 17

list the factors found on Roman’s cluster

Answer 17

1. Age > 52 years
2. no presence of leg pain
3. BMI = 22
4. doesn’t exercise regularly
5. Female gender

Question 18

what is the clinical utility of Roman’s cluster?

Answer 18

QUADAS score of 8

<2/5 -LR is good making it good for elimination

4/5 has +LR of 9.6

Question 19

list symptoms and physical exam findings of a rib fracture

Answer 19

1. Symptoms
   
   1. focal pain, radiating pain
   2. pain with inspiration
   3. pain with coughing/sneezing
2. Physical exam findings:
   
   1. focal tenderness
   2. possible palpable defect

Question 20

where is disc disease more common in the T-Spine?

Answer 20

lower T-Spine

Question 21

list the symptoms for disc disease in the T-Spine

Answer 21

1. back or chest pain
   
   1. radicular: band-like pain in affected level’s dermatome, paresthesia/anesthesia, leg pain
   2. back pain at midline
2. progressively/insidious (months to years)

Question 22

what is thoracic myelopathy?

what are related health conditions?

Answer 22

cord compression in the T-Spine

related health conditions: compression Frx, stenosis

Question 23

what are the symptoms and exam findings for thoracic spine myelopathy?

Answer 23

1. symptoms
   
   1. sexual dysfunction
   2. bowel and bladder dysfunction
2. Physical exam
   
   1. sensory/motor impairments
   2. UMN signs LEs

Question 24

what are some potential causes of intercostal neuralgia?

Answer 24

1. infection (varicella zoster)
2. mechanical compression
   
   • disc protrusion, osteophyte complex, neuroma, Frx
3. following a thoracic surgery

Question 25

list symptoms and physical exam findings for intercostal neuralgia

Answer 25

1. symptoms: 1. burning pain/paresthesia along intercostal nerve path 2. physical exam: 1. focal tenderness of intercostal area

Question 26

T/F: T4 syndrome is more commen in men?

Answer 26

FALSE women \> men (4:1)

Question 27

describe the etiology of T4 Syndrome

Answer 27

unknown theory → sympathetic reaction with hypomobile segment

Question 28

what are the primary pain generators in T4 syndrome?

Answer 28

thoracic IV discs thoracic zygophyseal joints

Question 29

list the symptoms for T4 syndrome

Answer 29

1. glove-like paresthesias unilateral/bilateral UEs 2. neck/scapular/bilateral UE pain * constant or intermittent * worsens w/side-lying or supine position 3. generalized HA

Question 30

list the physical exam findings for T4 syndrome

Answer 30

1. tender spinous processes (can be T2-7) 2. + thoracic slump test 3. + Upper quarter neurodynamic tension test 4. hypomobile thoracic segment

Question 31

what is scoliosis? describe its' etiology

Answer 31

abnormal curvature of the spine can be congenital or acquired

Question 32

how is scoliosis named/described?

Answer 32

by region of the spine and direction of CONVEXITY

Question 33

list the symptoms and physical exam findings for zygophysial arthropathies in the T-Spine

Answer 33

1. Symptoms: 1. local and/or referred pain 2. Physical exam: 1. painful movement with closing of z-joints (AROM and PROM) 2. painful spring testing/hypomobility with joint mobility testing

Question 34

rib dysfunction can be broken down into what 3 subcategories?

Answer 34

1. structural → subluxation of joint (anterior or posterior) 2. torsional → rib held in rotated position 3. respiratory → related to posture, may affect respiration

Question 35

list the symptoms and physical exam findings for rib dysfunction

Answer 35

1. symptoms: 1. aggravated with deep inspiration, trunk rotation, sneezing/coughing 2. physical exam: 1. diminished rib mobility (structural) 2. pain/hypomobility with joint mobility testing 3. limited/painful T-spine motion

Question 36

define thoracic outlet syndrome (TOS)

Answer 36

UE symptoms due to compression of the neurovascular bundle by various structures in the area just above the first rib and behind the clavicle

Question 37

list various structures that can be compressed in TOS

Answer 37

subclavian artery (ATOS) subclavian vein (VTOS) brachial plexus (NTOS) 90-95% of TOS

Question 38

list various areas of potential compression in TOS

Answer 38

1. scalenes 2. cervical rib 3. pec minor 4. first rib (hypertonic scalenes) 5. clavicle

Question 39

describe the clinical presentation of TOS

Answer 39

1. Hx of neck trauma 2. cervical rib (incidence \<1% of population) 3. Raynaud's phenomenon

Question 40

list symptoms of TOS

Answer 40

1. UE pain, paresthesia, anesthesia/weakness (glove-like vs. particular distribution consistent with area of compression 2. chest/anterior shoulder pain 3. typically progressive/insidious onset

Question 41

describe physical exam findings in TOS

Answer 41

1. guarding of cervicothoracic/scapulothoracic muscles 2. provocation with contralateral cervical lateral flexion (and/or combined rotation) 3. provocation with stretching any compressive muscles 4. vascular TOS associated with: * edema, cyanosis, coldness of hand, and diminished pulses 5. neurologic TOS associated with: * characteristics C8/T1 distribution LMN signs, possible atrophy abductor pollicis brevis

Question 42

list potentially positive special tests in TOS

Answer 42

1. Roo's Test 2. Hyperabduction Test 3. Adison's Test 4. Cervical Rotation lateral flexion test: restricted 1st rib 5. First rib spring test: restricted 1st rib

Question 43

what is Scheurmann's Disease?

Answer 43

a genetic condition in which there is a defective growth of the vertebral endplate and poor diffusion of nutrients to the unvascularized disc

Question 44

list risk factors for Scheurmann's Disease

Answer 44

increased risk in: 1. manual workers who begin at early age 2. young high intensity athletes 3. high BMI 4. anatomical variation of short sternum

Question 45

list the diagnositc criteria for Scheurmann's Disease

Answer 45

1. thoracic kyphosis \> 45 degrees 2. wedging x 3 adjacent vertebrae \> 5 degrees 3. Thoracolumbar kyphosis \> 30 degrees

Question 46

list the symptomology of Scherumann's Disease

Answer 46

1. thoracic pain 2. commonly apex of curvature (muscular tension, IV disc bulging/spondylosis)

Question 47

list some physical exam findings in individuals with Scheurmann's Disease

Answer 47

1. Scoliosis (15-20%) 2. Excessive thoracic kyphosis 3. Vertebral wedging, Schmorl's nodes (16-48%), disc space narrowing 4. Limited thoracic ROM 5. Neurologic Complications (less common)