thoracic spine

Question 1

T/S spinous process

rule of 3s

Answer 1

• 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

Question 2

articulations of the TS vertebrae

Answer 2

• 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

Question 3

rib joint articulations

Answer 3

• 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

Question 4

rib motions

Answer 4

• upper ribs to T5 move upward, forward in a pump handle motion
• lower ribs move upward, laterally in a bucket handle motion

Question 5

Thoracic discs

Answer 5

• 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

Question 6

T/S arthrokinetmatics

flexion and extension

Answer 6

• T/S vert tilt anterior
• facets slide foward and anterior
• disc compressed anterior
• rib rotates anterior
• oppositie for extension

Question 7

side bending arthrokinematics for T/S

Answer 7

• Ribs gap contralaterally
• ribs approximate ipslaterally
• relative anterior rib rotation isplaterally and facet goes down
• contralateral rib rotates posterior and facet slides up

Question 8

T/S arthrokinetmatics for rotation

Answer 8

• 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

Question 9

Mid and lower T/S SB and rotation athrokinematics

Answer 9

• occur in opposite directions
• however when in some flexion of spine (functional SB) SB and rotation occur to the same side

Question 10

Common conditions of T/S

Compression fractures of T/S

Answer 10

• commonly seen in T/S
• osteoporosis W>M
• vertebral body collagpses anterior
• anterior wedging
• hyperkyphotic posture

Question 11

Common conditions of T/S

MOI: compression fracture

Answer 11

• forced spine flexion
• axial load to spine
• fall on buttock
• sneeze/cough if severe osteoporosis

Question 12

Common conditions of T/S

medical treatment for compression fractures

Answer 12

• 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

Question 13

bracing for compression fractures

Answer 13

• 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

Question 14

Common conditions of T/S

Sheuermann’s disease

(osteochondrosis)

Answer 14

• 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

Question 15

Common conditions of T/S

Schmorl’s nodes

Answer 15

• herniation of disc thru vertebral end plate “modic disc”
• more common in males
• MOI: trauma, lifting, falling on buttock
• discitis from infection - need antibiotics

Question 16

Common conditions of T/S

costochondritis

Answer 16

• inflammation of costochondral junction/costal cartilage
• tender to palpation
• pain with breathing
• pain with trunk UE ROM
• differential diagnosis: cardiac referred pain, rib fracture

Question 17

patient exam: History and interview

red flags

Answer 17

• 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

Question 18

T/S observation:

posture and associated deformities

Answer 18

• 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

Question 19

T/S evalutation

ROM

Answer 19

• 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

Question 20

T/S evaluation

breathing assessment

Answer 20

• 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

Question 21

what could pain with breathing indicate

Answer 21

• ribs, spine or both
• intercostal muscles, accessory respiratory muscles
• costal cartilage
• lungs, diaphragm

Question 22

T/S exam

palpation

Answer 22

• 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

Question 23

T/S

mobility assessment

Answer 23

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

Question 24

clinical prediction rule for the T/S

for T/S manip

Answer 24

1. no symptoms distal to shoulder
2. symptoms less than 30 days
3. looking up does not aggravate symptoms
4. score < 12 FABQPA
5. decreased T/S kyphosis/flattening of T3-T5
6. cervical extension < 30

• 4/6 present = 93% success for T/S manip.
• 3/6 present = 86% of T/S manip

Question 25

factors for age related T/S hyperkyphosis in elderly

Answer 25

- 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