Thoracic Flashcards
Patient’s primary musculoskeletal symptom(s) may be directly or indirectly related or influenced by impairments from various body regions and systems regardless of proximity to the primary symptoms (true/false)
true
Restricted mobility in upper thoracic spine can affect cervical spine motion, as well as overall motion of thorax (true/false)
true
What effects can be seen in the sympathetic nervous system with thoracic mobilization?
increase blood flow in hands
The thoracic spine is very mobile (true/false)
false
second least mobile
Decreased mobility is due to
ribcage and low ratio of IVD height to vertebral body height
Where do ribs attach?
costovertebral and costotransverse joints
Facets favor which motion?
a. flexion
b. extension
c. side bending
d. rotation
rotation
the t-spine is vulnerable to
growth related deformities
age-related osteoporosis
flexion-compression fractures
height of body is slightly higher _ which contributes to normal kyphosis
posterior
each body has paired demi-facets posterio-laterally except _ _ _
T10, 11, and 12
Pedicles protrude directly
a. anterior
b. lateral
c. medial
d. posterior
posterior
(superior/inferior) facet slightly convex and posteriorly oriented
superior
(superior/inferior) facet slightly concave and face anteriorly, slightly inferiorly and medially
inferior
What structure resists buckling of vertical trabeculae under axial load?
transverse trabeculae
transverse processes project
laterally and slightly posteriorly
Which vertebrae level are considered typical thoracic vertebrae?
T4-T9
Which vertebrae levels are considered transitions?
T10, T11, T12
Spinous processes project
posteriorly and inferiorly
heads of 2nd to 10th ribs each articulate with (one/two) vertebral bodies
two
heads of 1st, 11th and 12th ribs each articulate with (one/two) vertebral bodies
one
costal cartilages of first 7 pairs attach to the
sternum
The head and tubercle of each rib articulate with the
vertebral body
transverse process of each side
Rib articulates with upper and lower _
facet
What does the rib articulate with?
a. Transverse process
b. Upper facet
c. Lower facet
d. Upper and lower facet
upper and lower facet
What is the ratio disc: body height in the t-spine?
a. 2:5
b. 1:3
c. 1:5
d. 2:3
1:5
The annulus is (stronger/weaker) in the thoracic spine
stronger
Why is the annulus in the thoracic spine stronger?
a. To load bear more weight
b. Support the rib cage
c. Because of the size of the vertebrae
d. To resist rotational stress
to resist rotational stress
What areas of cervicothoracic junction degenerate?
a. C7-T1
b. T1-T2
c. C6-7
d. C5-T2
C6-7
The upper t-spine costovertebral joint is designed to
a. Slide
b. Depress
c. Rotate
d. Glide
rotate
The lower t-spine and ribs form the costovertebral joint to
a. Rotate
b. Slide
c. Glide
d. None of the above
slide
What can be a primary site of sprain or irritation?
a. Costochondral junction
b. Costovertebral joint
c. Facet joint
d. Ribs
costochondral junction
Secondary pain caused by rib dysfunction will show
pain in the front
The ligaments for vertebrae and ribs positioned can be described as
Continuous ligamentous stocking
Which ligaments unite as a single unit?
Ligamentum flavum, interspinous ligament, supraspinous ligament, intertransverse ligament
Which ligament is a bridge between neural arch ligaments and those of the vertebral body?
a. ALL
b. Ligamentum flavum
c. Capsular ligament
d. Supraspinous ligament
ligamentum flavum
The capsule is reinforced dorsally by multifidus and ventrally by
a. Ligamentum flavum
b. Interspinous ligament
c. Supraspinous ligament
d. Capsular ligament
ligamentum flavum
Which motion does the thoracic spine mainly do?
a. Flexion
b. Rotation
c. Extension
d. Side bending
rotation
How does the vertebra move with flexion?
a. Posterior translation
b. Anterior translation
c. Rotates
d. None of the above
anterior translation
How do the ribs move with thoracic flexion?
a. Rotate backwards
b. Rotate sideways
c. Translate
d. Rotate forward
rotate forward
How does the vertebrae move with extension?
a. Posterior translation
b. Anterior translation
c. Rotation
d. None of the above
posterior translation
How do the ribs move with extension?
a. Rotate sideways
b. Rotate forward
c. Rotate backward
d. Translation
rotate backward
How does the vertebrae move with lateral flexion?
a. Translate anteriorly
b. Translate posteriorly
c. Translate in the direction side flexing
d. Rotates in the direction side flexing
Translate in the direction side flexing
How do the ribs move with lateral flexion?
a. Translate and rotate
b. Tip forward
c. Tip backward
d. Translate and tip to the same side lateral flexion
Translate and tip to the same side lateral flexion
What limits side flexion and stops motion?
ribs
With side bending to the right, the right rib (anterior/posteriorly) rotates and the left rib (anteriorly/posteriorly) rotates
anterior
posterior
What happens to the vertebrae with rotation?
Coupling of rotation with contralateral translation and ipsilateral lateral flexion
How do the ribs move with rotation?
a. Anteriorly rotate to the side rotating and posteriorly rotate to opposite side
b. Posteriorly rotate to the side rotating and anteriorly rotate to opposite side
Posteriorly rotate to the side rotating and anteriorly rotate to opposite side
Which areas function as part of the lower c-spine and upper t-spine?
a. T1-T4
b. T1-T2
c. T1-T3
d. T1-T5
T1-2
Which areas function as the true t-spine?
a. T9-T10
b. T11-12
c. T4-T9
d. T3-T10
T4-T9
Which areas function as part of the upper L spine and lower t-spine?
a. T8-T12
b. T10-12
c. T9-11
d. T10-11
T10-12
Load on the t-spine increases
a. In upper levels
b. In mid thoracic
c. In lower areas
in lower areas
Lower t-spine load transferred through _ _
posterior column
The lower angle of scapulae is aligned with
a. T1
b. T4
c. T7
d. T9
T7
What is designed to handle increased load demand?
Vertebral body height
End plate cross sectional area
Bone content
In the upper spine the load is transferred through the
Vertebral body/disc complex
How does the load distribution across end plate change outside the neutral position?
Becomes asymmetrical
Mid-thoracic pain can be associated with what type of postures
sustained loading postures
How does mechanics of shoulder and c-spine affect the t-spine?
may restrict functional motion
How does kyphosis change mechanics of the arm?
Limits ability for arm elevation
Risk with red flags increases with indication of
Age under 20 or over 50
Family history
Past personal history
Sudden, unexpected weight loss/gain
Which structure leads to endplate concavity?
a. Annulus fibrosis
b. Vertebral bodies
c. Trabeculae
d. Vertebral end plates
vertebral end plates
What leads to a collapse of load bearing of the spine?
a. Vertebral end plate fracture
b. Vertebral bodies lose bone trabeculae
c. Rib arthritis
d. Decrease bone density
Vertebral bodies lose bone trabeculae
The thoracic spine is (more/less) likely to become arthritic
Less
Because of rib cage protection
Height loss in females is due to
Compression of vertebrae
Vertebral body fracture twice as common as hip fracture (true/false)
true
Osteophytes of the t-spine is common which aging (true/false)
true
A patient has a sudden onset of symptoms aggravated by breathing and coughing on one side posteriorly, this could suggest
a. Facet joint dysfunction
b. Hypomobility
c. Hypermobility
d. Radiculopathy
hypomobility
(Hypomobility/hypermobility) is common in the thoracic spine
hypomobility
In which motion are vertebrae more commonly injured with trauma?
a. Extension
b. Rotation
c. Flexion or axial compression
d. Side flexion or axial compression unilaterally
Flexion or axial compression
Which type of traumatic injury is the most severe?
a. Bone bruising
b. Wedge compression
c. Endplate fracture
d. Burst fracture
burst fracture
In the upper t-spine _ causes more injury with thoracic facet injuries
a. Flexion
b. Extension
c. Axial compression
d. Rotation
extension
Which type of injury is common in the upper t-spine with MVC?
a. End plate fracture
b. Vertebral body injuries
c. Compression fracture
d. Bone bruising
vertebral body injuries
Which area is most frequently injured in a MVC?
a. Transitional zone
b. Upper t-spine
c. Lower t-spine
d. Mid thoracic
transitional zone
Falls and sudden flexion can cause
Sudden forceful flexion
Slipping
Sudden load onto the spine
Which levels are the highest at risk for a compression fracture?
a. T1,2,3
b. T5,6,7
c. T9,10,11
d. T11, 12, L1
T11, 12, L1
What is the risk with kyphoplasty?
high incidence of fractures
Ribs attach to _ _ which is related a higher incidence of _ _
Annulus fibers
Disc lesion
What potential causes of disc lesion injury?
High viscosity of IVD
Asymmetrical loading
Disc lesions are most commonly in what areas of the thoracic spine
lower t-spine
thoracolumbar junction
Patient presents with pain in blobs and patches, unilateral, deep ache. What could this suggest?
a. Radiculopathy
b. Facet joint injury
c. Costochondral injury
d. Disc lesion
disc lesion
Patients pain is distal and has severe pain
a. Radiculopathy
b. Facet joint injury
c. Costochondral injury
d. Disc lesion
radiculopathy
Radiculopathy in the thoracic spine can be due to
Disc lesion
Facet injury
Osteophytes
Scarring
_ can closely stimulate thoracic nerve root symptoms
costochondritis
The upper t-spine will refer symptoms into _ with radiculopathy
UE
Patient presents with localized sharp pain unilaterally and is aggravated by extension
a. Radiculopathy
b. Facet joint injury
c. Costochondral injury
d. Disc lesion
facet joint injury
Facet joint dysfunction causes neurological symptoms (true/false)
false
Pain with coughing and sneezing is common in the (acute/chronic) phase with facet joint dysfunction
acute
Dull and aching pain related to facet joint dysfunction is common in the (acute/chronic) phase
chronic
Small ligaments in the t-spine can cause
sprain
Pain is vague, ill defined, spread around the area but no pain distally or neurological symptoms
a. Rib cage injury
b. Facet joint injury
c. Disc lesion
d. Ligamentous injury
ligamentous injury
Both ALL and PLL are innervated by _ nerve
sinuvertebral
Breathing causes pain, tender to palpation with severe pain
a. Muscle injury
b. T4 syndrome
c. Ligament injury
d. Rib cage injury
rib cage injury
Spasms are common in the _ area
a. Lower thoracic
b. Thoracolumbar junction
c. Upper thoracic
d. None of the above
upper thoracic
Dull aching symptoms covering the whole hand with pins and needles, unilateral
a. Muscle injury
b. T4 syndrome
c. Ligament injury
d. Rib cage injury
T4 syndrome
T4 syndrome is commonly a (UE/LE) problem
UE
T4 syndrome is a problem involving which structure
facet joints
Lower t-spine and T/L junction refers to the
low back
hip
MSK and visceral conditions can be aggravated or alleviated with positional change (true/false)
true
With MVC (upper/lower) t-spine usually injure facet joints
upper
With MVC (upper/lower) t-spine usually injure vertebral bodies and disc
lower
Schmorls nodes are related to pain (True/false)
false
Scheurmanns Disease is associated with schmorls nodes (true/false)
true
Patient with thoracic dural attachment problems will present with _ in response to test flexion of spine in seated slump
headache
If a patients condition doesn’t change within _ visits, be suspicious and consider reexamination
6
The spinal cord unfolds with _
flexion
Which structure can facilitate trigger points?
posterior primary rami
What type of dysfunction can happen to the posterior primary rami?
entrapment
myelin removal
source of sensitization
facilitation of trigger points
Which tests can be done to see if the posterior primary rami is causing the problem?
slump longsit and add side flexion of the c-spine
What can cause a decrease in BF, ischemia, pH levels to drop?
prolonged posture
prolonged posture causing ischemia and scapular pain can be caused by
posterior primary rami
What contributes to pain caused by a rib fracture?
intercostal nerves
removal of myelin
scar tissue
Which test should be used to check T1, T2 nerve root and axilla?
ULNT3
Which structure is adjacent to costovertebral joint that can cause pain?
sympathetic ganglions
The path of the SNS gets altered due to
bone formation
thickening of ligaments
Increased stress on SNS tracks can be caused by
posture
aging
scoliosis
kyphosis
The sympathetic chain sits (anterior/posterior) to the c-spine and (anterior/posterior) to the t-spine
anterior
posterior
Extra load is added to the SNS with what type of postures
thoracic kyphosis
cervical extension
Where is the sympathetic chain located in the spinal area?
on the side of vertebral bodies
This is described as pain, paresthesia, weakness or discomfort in the upper limb and is aggravated by elevation of the arms or by exaggerated movements of the head and neck
a. kyphosis
b. thoracic outlet syndrome
c. T4 syndrome
d. rib injury
thoracic outlet syndrome
This diagnosis is the most underrated, overlooked and misdiagnosed peripheral nerve compression in the UE
a. radiculopathy
b. thoracic outlet syndrome
c. T4 syndrome
d. posterior primary rami injury
thoracic outlet syndrome
Pain and discomfort of TOS are caused by compression of the
subclavian artery
lower trunk of brachial plexus
Compression between anterior and middle scalene
a. site A
b. site B
c. site C
d. none of the above
site A
Compression between first rib and clavicle
a. site A
b. site B
c. site C
d. none of the above
site B
Compression under the pec minor attaching to the coracoid process
a. site A
b. site B
c. site C
d. none of the above
site C
What are the possible causes of TOS?
congential
traumatic
medical
posture
What soft tissue pathologies can cause TOS?
anterior scalene muscle hypertrophy
muscle fiber type adaptive transformation
spasm
excessive contraction post cervical trauma
How does posture cause TOS?
lowering the anterior chest wall with drooping shoulders and holding the head in a forward position
How can a trauma cause TOS?
bone remodeling after fracture of clavicle or first rib or posterior sublux of AC joint
What are the two types of TOS?
neurogenic
vascualr
Most patients with TOS fall into which category?
neurogenic TOS (nTOS)
What symptoms are important to diagnose with TOS?
postural exacerbation
A patient has neurological symptoms in their upper limb, changes in skin temp, pain with sustained shoulder elevation. This could suggest
a. TOS
b. T4 syndrome
c. rib injury
d. neurodynamic issues
TOS
A patient has swelling, pain in prolonged postures and pain when they hold a backpack on their side, this could suggest
a. TOS
b. T4 syndrome
c. rib injury
d. neurodynamic issues
TOS
What are typical aggs of TOS
sustained shoulder elevation suspensory holding activities lying on the arm carrying a backpack prolonged postures repetitive use of upper limb and hand dexterity
A patient with TOS will only have motor symptoms (true/false)
false
mixed spinal nerve
A patient with TOS will have restrictions with _ ROM
glenohumeral joint
in a patient with TOS, check the _ joint for instability
glenohumeral joint
Which motion can cause TOS?
repeated overuse in overhead position
with TOS, muscle weakness will be in _ _ muscle groups
C5, 6
C8, T1
a patient with TOS will have weak _ _
grip strength
Which ULNT test should be done for a patient that might have TOS?
a. UNLT 1
b. ULNT 2
c. ULNT 3
ULNT1
TOS screening tests are reliable (true/false)
false
Which type of scoliosis is the most common?
adolescent idiopathic scoliosis
What are the three classifications of scoliosis?
failure of formation
failure of segmentation
combination
This stage of scoliosis has spontaneous healing or surgery
a. infant
b. juvenile
c. adolescent
d. adult
infant
This stage of scoliosis has a poor prognosis and will grow
a. infant
b. juvenile
c. adolescent
d. adult
juvenile
This stage of scoliosis girls are diagnosed more than boys
a. infant
b. juvenile
c. adolescent
d. adult
adolescent
With this stage of scoliosis, there is spinal and joint degeneration
a. infant
b. juvenile
c. adolescent
d. adult
adult
Mild scoliosis is
a. 10-20 degrees
b. 10-25 degrees
c. 25-50 degrees
d. > 50 degrees
10-25 degrees
Moderate scoliosis is
a. 15-25 degrees
b. 25-40 degrees
c. 25-50 degrees
d. > 50 degrees
25-50 degrees
Severe scoliosis is
a. > 40 degrees
b. > 50 degrees
c. > 60 degrees
d. > 55 degrees
> 50 degrees
How does the curve progress with scoliosis?
torsion with eccentric loading of the spine and vertebral growth modulation
in scoliosis the rib is pushed (anteriorly/posteriorly) and the cage is (widened/narrowed)
posteriorly
narrowed
vertebral body in scoliosis distorted toward the (concave/convex) side
convex
The vertebral canal is narrower in scoliosis on the (convex/concave) side
convex
In scoliosis the spinous process deviates to the (convex/concave) side
concave
In scoliosis the rib is pushed laterally and anteriorly to the (concave/convex) side
concave
What happens to the muscles with scoliosis?
weakness
hypertrophy
muscle imbalances
trigger points
A passive neck flexion test will be positive in patients with scoliosis (true/false)
true
How does flexion change in a patient with scoliosis?
curve enlarges
How does extension change in a patient with scoliosis?
limited movement
How does side flexion and rotation change in a patient with scoliosis?
asymmetry
What exercise treatment should be considered for the upper t-spine?
cervical spine exercises
What exercise treatment should be considered for the true t-spine?
thoracic exercises
AP and PA
Ribs: rotation
What exercise treatment should be considered for lower t-spine?
spinal stabilization
load attenuation
weight bearing
Which area responds favorably to PA and AP movements?
mid-thoracic spine
What can produce a pain pattern that may mimic Cloward and cervical joint referral?
a. impaired posture
b. posterior primary rami
c. costochondritis
d. annulus
posterior primary rami
What other structures have the same pain pattern as posterior primary rami?
cloward areas
cervical facet joints
thoracic facet
What is the structural differentiator for the longsit slump test?
knee flexion
Which joint deteriorates very fast?
costovertebral
Which two ribs have no costotransverse joints?
the lowest 2
Which are the floating ribs?
11 and 12
This joint is described as the head of rib connecting to the lateral side of the vertebral body
costovertebral joint
This joint is of the articular facet on the rib tubercle to the anterior aspect of the transverse process
costotransverse joint
The costovertebral and costotransverse joint provide
stability
What are the two tests for restricted first rib?
cervical rotation lateral flexion
first rib spring test
This test is when the PT checks the pulse then the patient puts their arms in >90 degree abduction and ER, they hold then check for a pulse again
a. roos
b. wright
c. hyperabduction
d. adsons
hyperabduction
A positive hyperabduction test is indicated by
change in pulse, diminished or gone
This test is when the PT checks the pulse then the patient puts their arms in abduction and turn their head away from side testing and hold
a. roos
b. wright
c. hyperabduction
d. adsons
wright
This test is when the PT checks the pulse then the patient puts their arms in abduction and clasps their hands
a. roos
b. wright
c. hyperabduction
d. adsons
roos
A positive wright test is indicated by
change in pulse or paresthesia
This test is when the pt puts their arms at 15 degrees abduction and hold their breath, check pulse and rotate head towards that side
a. roos
b. wright
c. hyperabduction
d. adsons
adsons test
A positive adsons test is indicated by
a diminished pulse or goes away, paresthesia
the height of the body is projected posteriorly to contribute to which type of posturing
kyphosis
for safe thoracic manipulation be cautious to
a. decrease load
b. avoid doing them at all
c. decrease peak force
d. put them in the right position
decrease peak force
The thoracic spine has a (high/low) ratio of IVD height to vertebral body height
low
The laminae is designed to limit which motion
a. flexion
b. extension
c. rotation
d. side bending
extension
the facet joint is what type of joint
synovial
This ligament grouping is a bridge between neural arch ligaments and those of the vertebral body
capsular ligaments
_ reinforced dorsally by multifidus and ventrally by ligamentum flavum
a. neural arch ligaments
b. supraspinous ligament
c. ventral ligaments
d. capsule
capsule
What part of the rib articulates with the vertebral body and TP?
head and tubercle
Which nerve innervates the ALL and PLL which can be a source of pain?
sinuvertebral nerve
Which treatment is good for thoracic dura mater?
a. spinal stabilization
b. c-spine exercises
c. traction
d. manual therapy
manual therapy
Which neurodynamic tests should be done with a patient who has scoliosis?
passive neck flexion
slump
slump longsit
straight leg raise
T4 syndrome symptoms are (unilateral/bilateral)
unilateral
Which vertebral bodies are most frequently injured with MVC?
a. C7, T1
b. C6, T7
c. T12, L1
d. T11, T12
T12, L1
Spinous process alignment in the thoracic spine has (good/poor) reliability
poor
cervical rotation flexion test is testing the (same/opposite) side
opposite
What type of symptoms do patients with TOS complain of?
pain
paresthesia
weakness
Posterior subluxation of the AC joint can cause TOS (true/false)
true
