Thoracic Spine Flashcards
Name 2 risk factors for development of neck and thoracic pain
Prolonged sitting, physical inactivity
How many vertebrae are in the T-spine?
12
Name 4 functions of the T-spine.
Movement of the trunk
Contributes to respiration
Protection of thoracic viscera and spinal cord
Support and assists with movement of the upper limb
How many degrees of flexion, extension, lateral flexion and rotation can the T-spine achieve?
Flexion: 32
Extension: 26
Lateral flexion: 27
Trunk rotation: 85
What is non-specific thoracic back pain?
Most common type of thoracic related back pain
Unlikely to be because of a serious problem such as cancer, infection, fracture, or as part of more widespread inflammation
Nociceptive in origin
Range of sources; Intervertebral joint structures (IVD, Rib articulations, Z- joint), muscle and soft tissue.
What the mechanism of injury (MOI) of non-specific thoracic back pain?
Gradual onset: no specific incident, will report sustained posture (increased sitting/unaccustomed postures) or a recent change in activity (type, amount, technique)
Acute sudden: will report injury after a specific movement that involves lifting/rotation
What are the key impairments of non-specific thoracic back pain?
Loss of ROM - limited by pain/stiffness (soft tissue, muscle, articular)
Loss of strength & endurance - movement direction specific or activity related
What are the subjective features of non-specific thoracic back pain?
Symptoms between/around medial border of the scapulae, unilateral/bilateral
Rib involvement if symptoms 2 inches from midline +/- referral into rib
Mechanical in nature: Agg by activity or specific movements
What are the objective features of non-specific thoracic back pain?
Reduced ROM– particularly rotation and side flexion
Pain with breathing – may indicate rib involvement
Pain reproduction on accessory assessment
Posture and activity Ax: Altered movement/loading related to aggravating and easing factors
How would you manage non-specific thoracic back pain (specifically advice/education)?
Explain what is wrong: self limiting, will improve with time
Address fears and unhelpful beliefs
In the acute phase: Relative rest, encouragement of early (safe) return to activity
How would you manage non-specific thoracic back pain (symptom control)?
Reduce load/movement into aggravating positions
Encourage active pain free mobility, particularly those that ease symptoms
Postural education: Encourage changes in posture and positions regularly
Manual Therapy may be indicated for short term pain relief – never in isolation
How would you manage non-specific thoracic back pain (building capacity)?
- Restore normal movement: Address limitations in ROM
Exercises to increase mobility – particularly thoracic rotation and side flexion
Manual therapy for short term benefit may be indicated – never in isolation - Restore deficits in strength
Exercises to improve muscle strength and endurance within the thoracic spine: thoracic rotation, extension
Exercises to improve muscle strength and endurance involved scapulothoracic function: Rhomboids, serratus anterior, Trapezius - Postural control and advice
Particularly relevant to those who present with gradual onset related to sustained activities and postures
How would you manage non-specific thoracic back pain (return to function)?
- Advanced rehabilitation to build strength and conditioning in order for sufficiently strength, mobility and control towards specific goal/function/sporting activity
- Increase load and resistance particularly into previously identified impairments – ensure capacity is there
- Graded return to activity
What is thoracic outlet syndrome (TOS)?
What factors aggravate it?
Symptoms of pain, paresthesia, weakness and discomfort in the upper limbs caused by pressure on neurovascular structures (subclavian vein/artery/lower trunk of the brachial plexus) by upper ribs, clavicle or scalenes
- Elevation of the arms and related movements of the head and neck
What population does TOS mainly affect?
Female: male 4:1
30-40 years
Neurological structures affected 95-98% of the time
Vascular structures affected 2-5% of the time
What are the 3 possible site of entrapment in TOS?
Scalene triangle/interscalene space
Costoclavicular space
Subcoracoid (retropectoralis minor) space
What are 6 possible reasons that TOS develops?
Muscle length changes in scalenes and pecs which compress the neurovascular structures
Posture: that reduces the thoracic outlet space causing increase kyphosis & increased CT junction flexion
Occupational: repetitive overhead activities
Traumatic: post-fracture (clavicle, 1st rib, AC joint), whiplash
Congenital abnormalities: enlarged 1st rib tubercle/ cervical rib
What is/how does arterial TOS occur?
Compression of subclavian artery by the scalene triangle by a congenital 1st rib.
Arterial entrapment between the pec major tendon and humeral head (in active people)
How to recognise arterial TOS?
Change in blood pressure >20mmHg between arms
Symptoms: numbness, coolness, palor, (unusual paleness) non-radicular pattern of pain, no shoulder/neck symptoms
What does a non-radicular pattern of pain mean?
A pattern of pain NOT along the line of the nerve or distribution of a nerve root.
Possible complications of arterial TOS?
Claudication during activity/rest, turbulent blood flow and vessel dilation can cause arterial thrombosis (blood clot) and distal embolization (the detachment of athero or atherothrombotic fragments from the atherosclerotic plaque and their dislodgement downstream the peripheral portion of the coronary tree) can cause acute distal upper extremity ischemia.
How does venous TOS occur?
What are the symptoms of venous TOS?
Compression of the subclavian vein in the subclavian/costoclavicular space by the clavicle and 1st rib causing a disruption of blood flow.
Deep pain on movement/rest in the upper limb, chest, shoulder
Swelling and cyanotic discolouration (lack of O2 in the blood)
How does arterial or venous TOS develop (during what activity)?
Repetitive upper limb activities
Under what structures is there compression in neurogenic TOS?
What are the symptoms?
A compression of the
upper plexus (C5-7) or - (symptoms= with radiations into the chest, periscapular region, head and radial nerve distribution)
lower plexus (C8-T1) - (symptoms in ulnar forearm, hand, axilla and anterior shoulder region)
Compression of these nerve roots in the scalene triangle.
- Pain in neck, traps, arm +/- referral into chest & occipital headache
- Paraesthesia widespread in the upper limbs and fingers
What syndrome does neurogenic TOS mimic?
Carpal tunnel syndrome
Cubital tunnel syndrome
What objective tests (and the expected results) should be performed when neurogenic TOS is suspected?
Neural integrity assessment
Adsons test
Positive EAST
Neural test provocation test (NTPT)
What objective symptoms (and the expected results) should be performed when neurogenic TOS is suspected?
TOP on scalene triangle and subcoracoid space
Upper plexus (C5-7) - Sensory disturbance of the upper arm, weakness/atrophy of deltoid, biceps, brachialis
Lower plexus (C8-T1) - sensory changes in ulnar border of forearm and hand
Weakness/atrophy of small muscles of the hand, weak wrist finger flexion
What the symptoms of venous TOS ?
Upper limb swelling, cyanosis, distended collateral veins
What objective tests (and the expected results) should be performed when venous TOS is suspected?
Neural integrity assessment
Positive EAST (ROOS)
NTPT
Adsons test
What objective symptoms (and the expected results) should be performed when arterial TOS is suspected?
Raynauds phenomenon
Vascular changes
Sensory disturbances in upper arm - weakness/atrophy of deltoid, biceps, brachilais
What objective tests (and the expected results) should be performed when arterial TOS is suspected?
Neural integrity Blood pressure difference >20mmHg between arms Positive EAST (ROOS) NTPT Adsons test
What investigations diagnose TOS?
X-ray cervical spine and chest (may show cervical rib/elongated C7 transverse)
How to manage TOS conservatively? (advice/education)
Explain what is wrong: explain diagnosis and encourage compliance with a HEP and recommendations for task modification particularly those that aggravate/exacerbate symptoms
Address fears and unhelpful beliefs
Symptom Control:
Modify postures and positions that aggravate their symptoms
Avoid carrying heavy objects on affected upper limb in order to help prevent decrease in thoracic outlet and load onto neurovascular structures - important early on to help reduce symptoms and sensitivity
How to manage TOS conservatively? (building capacity)
Improve Thoracic outlet container
- Increase muscle length of reduced length structures: Scalenes, Pecs
- Manual therapy: 1st rib mobilsations – never in isolation
- Posture: Tsp Kyphosis, shoulder girdle, lower cervical spine
Restore deficits in strength
- Exercises to improve muscle strength and endurance
- Depressed & protracted scapula: Deltoids, upper traps, rhomboids. Post shoulder cuff
- Exercises to improve Scapulo-thoracic control
Serratus anterior, rhomboids, trapezius
Improve neural tissue mobility - Flossing/Sliders/gliders
Postural control and advice
- Tsp Kyphosis, shoulder girdle, Lower cervical spine
How to manage TOS conservatively? (surgical management)
Large percentage TOS will improve with conservative
Surgical management indicated if there is a structural cause to their problem - Cervical rib, enlarged first rib tubercle, fibrous bands
Surgical indicated especially in those with arterial and venous TOS due to high level of symptoms they present with but also the seriousness of vascular compromise
Decompression surgery of structures compressing the neurovascular bundle helps to restore normal vascular and neural function
What is Scheuermann’s disease?
A growth disorder caused by osteochondosis with degenerative changes to the disc and cartilage endplates
It results in a more pronounced kyphosis in the T-spine
It can predispose to later degenerative changes in the lumbar region
What causes Scheuermann’s disease?
Unknown
What is normal thoracic kyphosis ROM?
What is thoracic kyphosis in Scheuermann’s disease?
20-40 degrees
45-75 degrees
What age and sex is Scheurmann’s disease most prevalent?
Males>females
13-16 years
Is the most common cause of thoracic pain in this age group
What objective symptoms (and the expected results) should be performed when Scheurmann’s disease is suspected?
What investigations diagnose Scheuermann’s?
- Smooth rounded kyphosis, exaggerated on flexion
- 1/3 will also have a scoliosis
- Reduced spinal mobility: Extension++
- Reduced hamstring length
- Reduced iliopsoas length
X-ray, MRI
How to manage Scheurmann’s disease conservatively? (1. advice/ education 2. symptom control )
- Explain what is wrong: i.e. diagnosis & encourage compliance with a HEP
- Modification particularly those that aggravate/ exacerbate symptoms
- Address fears and unhelpful beliefs
- Explain what is wrong: i.e. diagnosis & encourage compliance with a HEP
- Modify postures and positions that aggravate their symptoms
- Postural correction (bracing)
- Modify postures and positions that aggravate their symptoms
How to manage Scheurmann’s disease conservatively? (build capacity)
Maintain/improve mobility
- Thoracic ROM exercises and stretches – rotation and extension
Strengthen/maintain strength within the thoracic spine
- Exercises to improve/maintain muscle strength and endurance in the thoracic spine
Increase muscle length of hamstrings (as it impacts the pelvis) and iliopsoas (as it impacts the thoracolumbar region)
How to manage Scheurmann’s disease conservatively? (return to function)
- Advanced rehabilitation to build strength and conditioning in order for sufficiently strength, mobility and control towards specific goal/function/sporting activity
- Continue to maintain thoracic mobility and strength to ensure necessary capacity for desired function is there
- Graded return to activity
