t-spine intro Flashcards
physiologic motion of the t-spine is influenced by:
the stabilizing forces and movements of the ribs
*rib cage and sternum add strength and stability to the t-spine
normally, inter-rib motions stop BEFORE
intervertebral motion
endranges of osteokinematic motion involve motion of the TP on a “FIXED” rib
costotransverse joint
has a convex/concave relationship with ribs 1-7/8 and is flat for ribs 8-10
this relationship can guide both rib motion and segmental motion
flexion
0- (25-45) degrees
tape change= ~2.7cm
opening segmental motion limited by:
supraspinatus
infraspinatus
capsular ligaments
posterior longitudinal ligament
posterior force on the nucleus
motion of the rib cage during flexion/extension
costovertebral
sternocostal
costochondral
extension
0-(25-45) degrees
tape change= ~2.5 cm
closing segmental motion limited by:
approximation of spinous processes
anterior forcé on the nucleus
lateral flexion
0- (20-40) degrees
opening and closing lateral segmental motion is limited by:
lateral and rib cage structures
lateral forces on the nucleus
motion of the ribs during lateral flexion
motion on the convex side: intercostal spaces widen- enlarges cage
motion on the concave side: intercostal spaces narrow
rotation
0-(35-50) degrees
“twisting and rotation” of the disc (rather than shear like in the lumbar spine) leads to greater ROM (3 degrees per segment compared to 1 degree in lumbar spine)
opening and closing rotational segmental motions limited by:
rib cage deformations
axis through the body of the vertebra (lumbar spine axis posterior to SP)
motion of ribs in rotation
bends ribs and costal cartilages- these structures help limit motion
ribs
connected to the vertebrae by synovial joints
- costovertebral joints
- costotransverse joints
costovertebral joint
head of rib (convex) articulates with both vertebral bodies (concave) and annulus.
consider as 2 pairs of articular facets separated by an interosseous ligament enclosed by a single capsule reinforced by the radiate ligament running forward to both vertebral bodies and annulus.
stable d/t interlocking joint surfaces
costotransverse joint
convex rib tubercle on concave transverse process for ribs 1-7 or 8; flat for 8-10 stabilized by 3 costotransverse ligaments:
- interosseus
- posterior costotransverse
- superior costotransverse
rib movement
occurs through an axis through both joints
UPPER RIBS: “Pump handle”
Axis lies closer to the frontal plane; raises sternum, expands A-P dimension of rib cage
MIDDLE RIBS:
Axis through roughly 45 degrees to frontal plane-transition, both types of motion present
LOWER RIBS: “Bucket handle”
Axis lies closer to the sagittal plane; expands medial/lateral dimension of rib cage and changes angle at sternocostal joint
INFERIOR RIBS: (11 &12)
“Caliper motion”
superficial layer of posterior muscles
traps
rhomboids
latissimus dorsi
2nd layer of posterior muscles
splenius
serratus posterior
3rd layer of posterior muscles
iliocostalis
longissimus
semispinalis
deepest layer of posterior muscles
levator costorum interspinalis intertransversarii multifidii rotatores
rib muscles
intercostals:
- external for inhalation
- internal for exhalation
levator costae: elevates ribs (inhalation)
sternocostalis (retrosternal location): exhalation
diaphragm: increases all 3 dimensions of the rib cage
impairment based classification system for t-spine
*(see olsen page 204)
- thoracic hypomobility
- TS hypomobility w/ UE referred pain
- TS hypomobility w/ neck pain
- TS hypomobility w/ LBP
- thoracic clinical instability
thoracic hypomobility
*common TS condition
- TS manipulation shows promise in the literature to increase movement and decrease pain complaints
- differentiate from rib hypomobility by MOTION TESTING
- rib and TS hypomobility can occur concurrently; treat the SPINE first, then address any lingering RIB hypo mobility
differentiate rib vs TS hypomobility by…
motion testing
TS hypomobility w/ UE referred pain
AKA “ T4 syndrome”
=UE paresthesia and pain w/ or w/out CS pain
- findings include T4 region stiffness, +ULTT
- ?sympathetic nervous system referral to CS, head and UEs
- evidence shows good success with upper TS manipulation followed by movement (level 4/case study level of evidence)
TS hypomobility w/ neck pain
Cleland CPR for TS manip for CS pain
-symptoms <30 degrees
if 3/6 present successful outcome increases from 54-86%
TS hypomobility w/ shoulder impairments
- decreased upper TS mobility may predispose RC impingement
- check PIVM of the TS
- observe TS during active elevation; re-checl with manual retraction of the scapula
- include mob/manip and postural re-education
TS hypomobility w/ LBP
- lower TS stiffness may increase demand on the lumbar spine
- remember the linkage of the thoraco-lumbar fascia
- manipulation of the TS may help inhibit hyperactive T/L musculature
thoracic clinical instability
Less common than hypomobility conditions
Look for ache w/ sustained upright posture, relief with recumbent positions, aberrant movement w/ AROM, and hypermobile PIVM
Associated with:
- systemic hypermobility
- severe postural deviations
- S/P trauma
- S/P TS surgery
Red flags/risk factors
- minor trauma (osteroporosis/cortisone use)
- major trauma
- fever, pm sweats, risk factor for infection
- hx of malignancy, age >50, no improvement w/ treatment, unexplained weight loss, pain at multiple sites, pain at rest, pm pain
- chest pain/heaviness, no mechanical link to pain, abdominal pain, SOB, cough
patho-anatomical considerations
SPRAINS/STRAINS
- overuse/posture: most common reason for TS pain
- trauma
THORACIC PAIN D/T PROBLEMS EXTERNAL TO TS
- referral from abdominal and thoracic organs
- referral from CS
THORACIC DISC LESIONS
- root pain can mimic fractured rib or chondral problems; r/o w/ AP pressure on sternum=no pain w/ disc lesion
- also mimics visceral disease (angina, gall bladder, colitis, etc)
VERTEBRAL PROBLEMS Fractures: 3 columns: -anterior= usually not big problems -middle= usually BIG problems -posterior= instability not uncommon -Schmoral's nodes= usually no problems Segmental Problems: instability/hypermobility -surgical: rods, plates,, pedical screws -conservative: stabilization exercises, orthoses, corsets, strapping
rib dysfunction: fractures
fractures: ribs and costal cartilage
usually treated conservatively w/out immobilization-watch for pnuemothorax
rib dysfunction: costochondritis
usually trauma or infection (diff dx from MI)
- painful swelling of costochondral junction
- localized, palpable swelling
- pressure on sternum or lateral border elicits pain at junction
- pain w/ deep breathing/coughing
conservative tx: NSAID, rest, occ injected
posture
assess along w/ C-spine, shoulder girdle, lumbar spine and LE alignment
proprioceptive cues for posture
- corsets
- taping
