thoracic spine Flashcards
T/S spinous process
rule of 3s
- T 1-3 are in line with own TP
- T4-6 SP runs 1/2 way down to TP of vertebra below
- T7-9 SP runs down to TP of vertebrae below
Last 3:
- T 10 SP runs down to TP of vertebra below
- T 11 SP runs 1/2 down to TP vertebra below
- T12 SP in line with own TP
articulations of the TS vertebrae
- 4 facet joints: superior and inferior each side and oriented from 60-90
- 2 costotransverse joints 1 on each side
- longer slender TP
- 2 disc vertebral body articulations above and below
- 4 costovertebral joints 2 on each side for rib heads
rib joint articulations
- costo-transverse jt
- costoverebral joints: superior costal facet of vertebrae inferior costal facet of vertebrae above
execptions:
- rib 1 articulates with T1 only
- ribs 11 and 12 articulate with their respective verebral bodies
rib motions
- upper ribs to T5 move upward, forward in a pump handle motion
- lower ribs move upward, laterally in a bucket handle motion
Thoracic discs
- thinner in T/S
- less incidence of disc pathology (herniation)
- but if herniated, discs can cause thoarcic symptoms
- NR/radicular pain follows ribs from posterior to anteiror alone dermatome
T/S arthrokinetmatics
flexion and extension
- T/S vert tilt anterior
- facets slide foward and anterior
- disc compressed anterior
- rib rotates anterior
- oppositie for extension
side bending arthrokinematics for T/S
- Ribs gap contralaterally
- ribs approximate ipslaterally
- relative anterior rib rotation isplaterally and facet goes down
- contralateral rib rotates posterior and facet slides up
T/S arthrokinetmatics for rotation
- facets gap on side vertebra bodies are rotating to
- facets approximate on opposite side
right rotation - R ribs move backward sequentially on one another
- L ribs move forward sequentially on one another
Mid and lower T/S SB and rotation athrokinematics
- occur in opposite directions
- however when in some flexion of spine (functional SB) SB and rotation occur to the same side
Common conditions of T/S
Compression fractures of T/S
- commonly seen in T/S
- osteoporosis W>M
- vertebral body collagpses anterior
- anterior wedging
- hyperkyphotic posture
Common conditions of T/S
MOI: compression fracture
- forced spine flexion
- axial load to spine
- fall on buttock
- sneeze/cough if severe osteoporosis
Common conditions of T/S
medical treatment for compression fractures
- to stabilize collapsed vertebral body
- guided by fluoroscopic technique
percutaneous vertebroplasty
- injection of bone cement into vertebral body
Kyphoplasty:
- ballon first inserted and inflated to expand collapsed vertebral body
- bone cement then inserted
- studies show no difference in pain and outcome with above techniques vs placebo
bracing for compression fractures
- extension (jewtt) brace - 3 points system to avoid flexion
- unload fractured vertebral body
- allow healing
- prevent kyphotic deformtiy
- once healed: PT ROM and core strength
- careful with early flexion activites that load vertebral body
Common conditions of T/S
Sheuermann’s disease
(osteochondrosis)
- anterior wedging of T/S vertebral bodies
- unknown cause
- first seen in 8-12 year olds
- hyperkyphosis
- angulation at apex of kyphosis
- deformtiy remains in prone
- bracing effective if done early
- stops progressing with skeletal maturity
Common conditions of T/S
Schmorl’s nodes
- herniation of disc thru vertebral end plate “modic disc”
- more common in males
- MOI: trauma, lifting, falling on buttock
- discitis from infection - need antibiotics
Common conditions of T/S
costochondritis
- inflammation of costochondral junction/costal cartilage
- tender to palpation
- pain with breathing
- pain with trunk UE ROM
- differential diagnosis: cardiac referred pain, rib fracture
patient exam: History and interview
red flags
- cancer: breast, lung, thyroid, mets to T/S, constant pain
- infection: sweats, fever, chills
- cardiac: pain anteiror chest, arm, neck, jaw, pain upon exertion
- compression fx: hx of osteoporosis/decreased BMD, MOI?
- shingles: pain follows dermatome - rash?
- HNP disc: radiulopahy
T/S observation:
posture and associated deformities
- thoracic kyphosis with foward head, rounded shoudlers
- common in elderly, or in young people with disease and gamers
- compression fx: anterior wedging => kyphosis
- neck pain, headaches, TOS, shoulder impingement
- scoliosis - structural rib hump
- dowagers hump - marked U/T kyphosis (fluid in that area is assoicated with lack of movement)
- large breast size: kyphotic posture with strain and pain
T/S evalutation
ROM
- quantity, quality of motion
- amount/aberrant motion present
- what motions make it better/worse
- U/T increase kyphosis (dowagers): restricted UT extension
- MT spine T4-T7 = stiff and flat: restricted ROM flexion and extension
- LT T8-T12: stiff with kyphosis - restricted extension
- thoraco-lumbar junction - angulation stress point
- scoliosis - structureal with rib hump + adams test
T/S evaluation
breathing assessment
- upon deep breath observe
- rib pattern upper vs lower/diaphragmatic breathing
- chest expansion measured at 4th intercostal space < 1.5 - anklosing spondylitis
- pain with breathing
what could pain with breathing indicate
- ribs, spine or both
- intercostal muscles, accessory respiratory muscles
- costal cartilage
- lungs, diaphragm
T/S exam
palpation
- vertebral position: palpate between SP for malalignment or rotation = positional fault
- rib position: in relation to other ribs and contralateral ribs
- soft tissue: traps, rhomboids, ES, intercostals, pectoralis major or minor, serratus anterior, pain, trigger points, spasm, guarding, swelling
T/S
mobility assessment
joint play
- thoarcic vertebrae prone use V finger placement on TP with other hand hypothenar on top making a finger bridge
- PA on bilateral TP of segments
- rotation via PA on inferior opposite side TP
- rule of lower finger = superiro vertebrae rotation to side of lower finger
PPIVM:
- palpate segmental motion during movemetns of FB, BB, SB, rotation
clinical prediction rule for the T/S
for T/S manip
- no symptoms distal to shoulder
- symptoms less than 30 days
- looking up does not aggravate symptoms
- score < 12 FABQPA
- decreased T/S kyphosis/flattening of T3-T5
- cervical extension < 30
- 4/6 present = 93% success for T/S manip.
- 3/6 present = 86% of T/S manip
factors for age related T/S hyperkyphosis in elderly
- W>M
- anterior wedging of vertebra body for fx or DD
- spine extensors and scapular retractors weak
- hypomobility of T/S
- tight pectoral muscles
- kyphosis means > risk of falls
- breathing can be compromised