Thoracic Spine Flashcards
Why is the thoracic spine considered the most rigid part of the spine?
Because of the ribcage, yet it is also relied upon for mobility.
What type of curvature is found in the thoracic spine?
A mild primary kyphotic curvature.
What percentage of overall body length does the thoracic spine comprise?
20% of overall body length.
Why is the thoracic spine crucial for movement and control?
It serves as the site of global and local/intrinsic muscle attachments, including those for the shoulder girdle, cervical spine, and pelvic girdle. Almost every task requires load and power transfer through the thorax.
How does mid-thoracic dysfunction affect other regions of the body?
It can contribute to faulty posture, glenohumeral impingement, and TMJ disorder.
Why are thoracic spine complaints often overlooked?
Low-grade thoracic spine pain is common but is frequently overshadowed by neck and low back pain.
Why are nerve/IVD lesions and radicular pain rare in the thoracic spine?
Due to the structural integrity of the thoracic region.
Which degenerative conditions commonly affect the thoracic spine?
Degenerative joint disease, osteoarthritis (especially in the upper thoracic spine), and rheumatoid arthritis.
What is the most common disease affecting the thoracic spine?
Osteoporosis, which can lead to vertebral compression fractures.
What conditions should be ruled out when assessing thoracic spine issues?
Ankylosing spondylitis, nerve lesions (e.g., shingles, intercostal neuropathy), visceral referral pain, and systemic diseases.
How many thoracic vertebrae are there?
12 (T1-T12).
What is the shape of the thoracic vertebral body?
Heart-shaped.
How do thoracic IVDs compare to those in other spinal regions?
They are flatter and more narrow.
Describe the shape and orientation of thoracic spinous processes.
They are long, pointy, and project inferiorly and posteriorly, restricting extension.
How do the facet joints of the thoracic spine differ along its length?
The facets are vertically oriented along the coronal plane, with an angle of 60° in the upper thoracic spine and increasing to 80-90° caudally.
What vertebrae are considered the upper thoracic spine?
T1-T2.
What vertebrae are considered the lower thoracic spine?
T3-T12.
What are transitional vertebrae in the thoracic spine, and why are they important?
T1 (cervicothoracic junction) and T12 (thoracolumbar junction); they can move in unison with their adjacent vertebrae.
Describe the “Rule of Three” for the thoracic spine.
• T1-T3: Transverse process (TP) and spinous process (SP) are at the same level.
• T4-T6: TP is ½ level above the SP.
• T7-T9: TP is 1 full level above the SP.
• T10: TP is 1 full level above the SP.
• T11: TP is ½ level above the SP.
• T12: TP and SP are at the same level.
What is the movement of the inferior facets of the superior motion segment during flexion?
They glide up and forward (open).
What is the movement of the inferior facets of the superior motion segment during extension?
They glide down and back (close).
What happens to the facet joints during right lateral flexion?
The facets close on the right side and open on the left.
What happens to the facet joints during right rotation?
The facets close on the right and open on the left.
What is the range of motion for thoracic spine flexion?
20-45°.
What is the range of motion for thoracic spine lateral flexion?
20-40°.
What is the range of motion for thoracic spine extension?
25-45°.
What is the range of motion for thoracic spine rotation?
35-50°.
Why is the thoracic spine considered the most rigid part of the spine?
Because of the ribcage, which restricts movement while also providing stability.
Despite its rigidity, why do we rely on the thoracic spine to be mobile?
It plays a key role in transferring loads and power through the thorax, which is essential for almost every task.
What type of curvature does the thoracic spine have?
A mild primary kyphotic curvature.
What percentage of the overall body length does the thoracic spine make up?
20%
Why is the thorax important for muscle attachments?
It serves as the site for both global and local/intrinsic muscle attachments, including those of the shoulder girdle, cervical spine, and pelvic girdle.
How can mid-thoracic dysfunction affect other regions?
It can contribute to faulty posture, glenohumeral impingement, and TMJ disorders.
Why are thoracic spine complaints often overlooked?
They are typically overshadowed by neck and low back pain.
Why are nerve/IVD lesions and radicular pain rare in the thoracic spine?
Due to the structural integrity of the region.
What are common conditions affecting the thoracic spine?
Degenerative joint disease, osteoarthritis (especially in the upper thoracic spine), and rheumatoid arthritis.
What is the most common disease affecting the thoracic spine?
Osteoporosis
What conditions should be ruled out when assessing thoracic spine pain?
Ankylosing spondylitis, nerve lesions (e.g., shingles, intercostal neuropathy), visceral referral pain, and systemic diseases.
How many thoracic vertebrae and IVDs are there?
12.
What is the shape of the thoracic vertebral body?
Heart-shaped.
How do thoracic IVDs compare to those in other spinal regions?
They are flatter and more narrow.
How are the spinous processes of thoracic vertebrae oriented?
They are long, pointy, and project inferiorly and posteriorly, restricting extension.
How do facet surfaces in the thoracic spine change from upper to lower thoracic vertebrae?
They become more vertical, transitioning from 60° in the upper thoracic spine to 80-90° caudally.
Which vertebrae are considered transitional vertebrae in the thoracic spine?
T1 (cervicothoracic junction) and T12 (thoracolumbar junction).
How are the upper and lower thoracic spine defined?
T1-T2 are upper thoracic, while T3-T12 are lower thoracic.
What is the Rule of Three for thoracic vertebrae?
• T1-T3: TP and SP are at the same level.
• T4-T6: TP is ½ level above the SP.
• T7-T9: TP is 1 full level above the SP.
• T10: TP is 1 full level above the SP.
• T11: TP is ½ level above the SP.
• T12: TP and SP are at the same level.
What happens at the thoracic facet joints during flexion?
The inferior facets of the superior motion segment glide up and forward (open).
What happens at the thoracic facet joints during extension?
The inferior facets of the superior motion segment glide down and back (close).
What happens at the thoracic facet joints during lateral flexion to the right?
The right facets close, and the left facets open.
What happens at the thoracic facet joints during rotation to the right?
The right facets close, and the left facets open.
What is the range of motion for thoracic flexion?
20-45°.
What is the range of motion for thoracic lateral flexion?
20-40°.
What is the range of motion for thoracic extension?
25-45°.
What is the range of motion for thoracic rotation?
35-50°.
What role do the ribs play in spinal stability?
They restrict forward bending, side bending, and rotation while also protecting the viscera.
What are the atypical ribs, and what makes them different?
Ribs 1, 11, and 12 are atypical because they articulate with only one vertebral body, are not united to a disc, and articulate only with their numerically corresponding vertebral body.
How do typical ribs articulate with the vertebrae?
They articulate with two vertebral bodies (the numerically corresponding vertebral body, the IVD, and the vertebral body above).
Which ribs are floating ribs?
Ribs 11 & 12.
How do ribs 1 & 2 articulate anteriorly?
They articulate with the manubrium.
How do ribs 3-7 articulate anteriorly?
They articulate with the sternum.
What are costovertebral joints (CVJ)?
Joints where the rib head connects to a thoracic vertebral body.
What are costotransverse joints (CTJ)?
Joints where the facet of the rib tubercle connects to the adjacent transverse process of a thoracic vertebra.
What happens to the ribs when the mid-thoracic spine flexes?
The ribs roll anteriorly and glide superiorly.
What happens to the ribs when the mid-thoracic spine extends?
The ribs roll posteriorly and glide inferiorly.
What happens to the ribs when the mid-thoracic spine laterally flexes?
The ribs approximate ipsilaterally and separate contralaterally.
What happens to the ribs when the mid-thoracic spine rotates?
The ipsilateral rib rotates posteriorly, and the contralateral rib rotates anteriorly.
What structures make up a thoracic ring?
A thoracic ring consists of:
• Left and right ribs of the same number
• The vertebrae they attach to
• Anterior costal attachments (sternum/manubrium)
How many complete and incomplete thoracic rings are there?
10 complete rings (1-10) and 2 incomplete rings (11 & 12).
What happens to the thoracic rings during flexion?
They anteriorly tilt.
What happens to the thoracic rings during extension?
They posteriorly tilt.
What happens to the thoracic rings during side bending?
The vertebrae side flex ipsilaterally, ribs approximate ipsilaterally, and ribs separate contralaterally.
What happens to the thoracic rings during rotation?
The ipsilateral rib rotates posteriorly, the contralateral rib rotates anteriorly, and the vertebra shifts to the contralateral side.
What are the functions of the ribs?
The ribs contribute to spinal stability by restricting forward bending, side bending, and rotation. They also protect the viscera.
What makes ribs 1, 11, and 12 atypical?
Atypical ribs articulate with only one vertebral body, are not united to a disc, and articulate only with the numerically corresponding vertebral body.
What characterizes typical ribs?
Typical ribs articulate with two vertebral bodies (the numerically corresponding vertebral body and the vertebral body above, along with the IVD). They have a head with two facets on either side of a tiny crest.
Which ribs are floating ribs?
Ribs 11 and 12.
Where do ribs 1 and 2 articulate anteriorly?
With the manubrium.
Where do ribs 3-7 articulate anteriorly?
With the sternum.
What is the function of costovertebral joints (CVJ)?
They connect the rib head to a thoracic vertebral body.
What is the function of costotransverse joints (CTJ)?
They connect the facet of the tubercle of the rib to the adjacent transverse process of a thoracic vertebra.
What happens to the ribs when the mid-thoracic spine (T3-T9) flexes?
The ribs roll anteriorly and glide superiorly.
What happens to the ribs when the mid-thoracic spine extends?
The ribs roll posteriorly and glide inferiorly.
What happens to the ribs during lateral flexion of the thoracic spine?
The ribs approximate ipsilaterally and separate contralaterally.
What happens to the ribs during rotation of the thoracic spine?
The ipsilateral rib rotates posteriorly, while the contralateral rib rotates anteriorly.
How many joints are in the thorax?
136 joints.
How does thoracopelvic rotation contribute to movement?
It generates core power for activities like kicking, swinging a bat, racket, or golf club.
Why is thoracic mobility and control important?
It allows the trunk to act as a spring during compressive loading.
How does the thorax adjust for changes in the center of mass over the base of support?
It helps manage lateral shifts in balance.
What structures make up a thoracic ring?
Two ribs (same number), the vertebrae they attach to, and the anterior costal attachments to the sternum or manubrium.
What structures form the 4th thoracic ring?
Left and right 4th ribs, T3, T4, 4th costocartilages, and sternum.
How many complete thoracic rings are there?
10 (T1-T10).
How many incomplete thoracic rings are there?
2 (T11 & T12).
What is required for optimal biomechanics of the thoracic rings?
The entire ring must be intact.
What happens to thoracic rings during trunk flexion?
They tilt anteriorly.
What happens to thoracic rings during trunk extension?
They tilt posteriorly.
What happens to the thoracic rings during trunk side bending?
The vertebrae and ribs approximate ipsilaterally and separate contralaterally.
What happens to the thoracic rings during trunk rotation?
The ipsilateral rib rotates posteriorly, the contralateral rib rotates anteriorly, and the vertebra shifts contralaterally.
What are the primary muscles of inspiration?
• Diaphragm
• Levator costorum
• External intercostals
• Internal intercostals (anterior)
What are the secondary muscles of inspiration?
• Scaleni
• SCM
• Trapezius
• Serratus anterior & posterior
• Pectoralis major & minor
• Subclavius
• Latissimus dorsi
• Serratus posterior superior
• QL
• Iliocostalis lumborum
What are the muscles of expiration?
• Internal obliques
• External obliques
• Rectus abdominis
• Transversus abdominis
• Transversus thoracis
• Transverse intercostals
• Internal intercostals (posterior)
What is the primary muscle of respiration?
The diaphragm.
What shape is the diaphragm?
Dome-shaped.
Why is the right side of the diaphragm slightly higher than the left?
Due to the presence of the liver.
What is the innervation of the diaphragm?
C3, C4, C5 (phrenic nerve).
What is the diaphragm’s origin?
Xiphoid process, lower 6 cartilages, lower 4 ribs, upper lumbar vertebral bodies via crura, medial/lateral arcuate ligaments.
What is the diaphragm’s insertion?
The central tendon, which is boomerang-shaped and non-contractile.
What happens during inspiration?
• The diaphragm contracts, causing the central tendon to descend.
• Thoracic cavity volume increases while pressure decreases.
• Air is drawn into the lungs.
What happens during expiration?
• The diaphragm relaxes (or eccentrically contracts).
• The dome ascends.
What is the “pump-handle” action?
The elevation of the upper ribs & sternum, increasing the anteroposterior diameter of the thorax.
What is the “bucket-handle” action?
The lateral movement of the lower ribs (ribs 7-10), increasing the transverse diameter of the thorax.
What is the “caliper” action?
The lateral movement of the lower ribs to increase the lateral diameter.
What happens to the spine and ribs during inhalation?
The spine extends, ribs expand, rotate posteriorly, and glide inferiorly where they meet the spine.
What happens to the spine and ribs during exhalation?
The spine flexes, ribs rotate anteriorly, and glide superiorly where they meet the spine.
What muscles interdigitate with the diaphragm?
Transversus abdominis, QL, and psoas major.
How can the diaphragm be treated?
Through MET, fascial work, or breath retraining.
Where in the spine are vertebral compression fractures (VCFs) most commonly found?
VCFs are particularly common in the lower thoracic region.
What is the main cause of vertebral compression fractures (VCFs) in older patients?
Osteoporosis.
What postural deformity may be present with vertebral compression fractures (VCFs)?
A Dowager’s hump and an increased kyphosis due to anterior vertebral body collapse and forward tipping.
What is the primary cause of vertebral compression fractures (VCFs) in younger patients?
Physical trauma.
How does decreased physical activity contribute to vertebral compression fractures (VCFs)?
It increases the risk of VCFs; therefore, resistance and weightbearing exercises are preventative measures.
What should be done if an undiagnosed vertebral compression fracture (VCF) is suspected?
Refer out for medical evaluation.
What are the medical treatment options for vertebral compression fractures (VCFs)?
Treatment ranges from pain management and short-term modification of ADLs to surgical intervention if stability is a concern or if nerves or the spinal cord are at risk.
How is scoliosis defined according to Kendall?
“A lateral curvature of the spine. Because the vertebral column cannot bend laterally without also rotating, scoliosis involves both lateral flexion and rotation.”
What percentage of the population is affected by scoliosis?
2-4% of the population.
What percentage of scoliosis cases are idiopathic?
80%.
When does scoliosis typically onset in adolescents?
Between ages 10-15 years, when rapid growth spurts occur.
Why is scoliosis more prevalent in adolescent females?
Because they undergo puberty before musculoskeletal maturity.
What regions of the spine are usually affected by scoliosis?
The thoracic and lumbar regions.
Is scoliosis typically symptomatic?
No, it is typically asymptomatic.
What are the common physical signs of scoliosis?
• Rib prominence
• Elevated shoulder and/or prominent shoulder blade
• Uneven hip, arm, or leg lengths
• Uneven musculature, impaired mobility, and muscle performance
Is back pain considered a symptom of scoliosis?
No, back pain is not usually considered a scoliosis symptom.
What are the pulmonary and cardiac risks associated with scoliosis?
Severe curves can compress the ribcage, which may lead to pulmonary and cardiac complications, especially in left thoracic rotation curves (levoscoliosis).
What are the neurological risks of severe or progressive scoliosis?
Neurological complications may develop.
How can scoliosis affect the gastrointestinal system?
It can cause gastrointestinal disturbances.
What symptoms require further medical investigation in scoliosis patients?
Radiating leg pain, night pain, or systemic complaints such as bowel/bladder dysfunction.
How is scoliosis labeled?
Based on the convex side (right or left), curve shape (C-curve or S-curve), severity (degrees of rotation), transitional vertebra, span (start and end points), and apex (vertebra furthest from midline).
What is the Cobb method used for?
Measuring the severity of scoliosis curves.
What are the classifications of scoliosis severity?
• <10°: Normal
• 10°-20°: Mild
• 20°-50°: Moderate
• 50°: Severe
How do the vertebral bodies rotate in scoliosis?
They rotate toward the convexity of the curve and become distorted.
What does rib humping indicate in scoliosis?
In the thoracic spine, ribs on the convex side push posteriorly, causing a rib hump and a narrowing on that side.
What occurs to the ribs on the concave side of a scoliotic curve?
They shift more anteriorly, creating a “hollow” appearance and widening the thoracic cage.
Is functional scoliosis reversible?
Yes, it can be altered with forward/side bending and positional changes.
What are common causes of functional scoliosis?
• Leg-length discrepancy
• Bony asymmetries
• Muscle guarding/spasms
• Habitual or occupational postures
• Altered soft tissue integrity (contractures, trigger points)
• Antalgic lean/gait
How is functional scoliosis tested?
Using Adam’s Forward Bend Test.
Is structural scoliosis reversible?
No, it is a fixed deformity and does not correct with positional changes.
What is the most common type of structural scoliosis?
Idiopathic scoliosis.
What factors contribute to idiopathic scoliosis?
Genetics, tissue imbalances, hormonal, and/or neurological components.
What are the age classifications of idiopathic scoliosis?
• Infantile (0-3 years)
• Juvenile (4-10 years, highest risk)
• Adolescent (>11 years, most common)
• Adult (>18 years)
What causes congenital scoliosis?
Disturbances in vertebral development (failures of formation or segmentation).
When does congenital scoliosis typically occur?
During the first 6 weeks of embryonic formation.
What conditions are associated with neuromuscular scoliosis?
• Neuropathic diseases (cerebral palsy, poliomyelitis, upper/lower motor neuron lesions)
• Myopathic diseases (muscle weakness, stiffness, spasms)
How does neuromuscular scoliosis typically present?
As a long C-curve from cervical to sacral regions.
What are key factors in scoliosis treatment decisions?
Age and curve progression.
What interventions are considered at different curve severities?
• 20°-30°: Observation and treatment interventions
• 30°-40°: Bracing
• 40°-45°: Surgical interventions
What is the purpose of bracing in scoliosis?
To prevent further progression of the curve.
What is the goal of scoliosis surgery?
To stop curve progression, correct deformity in all three planes, and fuse the spine using devices like Harrington rods.
How do treatment goals differ between functional and structural scoliosis?
• Functional Scoliosis: Improve postural alignment, body awareness, and breathing patterns.
• Structural Scoliosis: Monitor functionality, manage symptoms, and maintain soft tissue adaptations.
What are rib fractures generally associated with?
Rib fractures are generally associated with distinct trauma and present with acute pain in all motions of the spine.
Can rib fractures always be seen on an initial X-ray?
No, a rib fracture may not show up on an initial X-ray, but a bony callus might be visible if X-rays are taken again once healing has begun.
What should you do if you suspect a recent rib fracture?
Refer the patient out.
How should you treat old rib injuries?
Treat scar tissue and adhesions of associated fascia and muscle to improve breathing. Rib and thoracic spine mobilization may also be indicated once healing has occurred.
What structures are involved in rib dysfunction?
Rib dysfunction includes costovertebral and costotransverse joints and surrounding soft tissues as pain generators.
What are some potential causes of rib dysfunction?
It may occur acutely after trauma or simple mechanical motion (e.g., coughing, rolling in bed). Chronic presentations may be due to mechanical stressors like postural habits (e.g., office workers).
What are the clinical presentations of rib dysfunction?
• Sharp, sometimes stabbing pain
• Aggravated by specific movements
• Upper ribs aggravated by reaching
• Lower ribs aggravated by bending/twisting
• Pain increases with sneezing, coughing, deep breaths
• Paraspinal tenderness/hyperalgesia
How are rib dysfunctions named?
They are named based on the position of ease for the patient.
What is an exhalation dysfunction?
A rib that fails to move fully into inhalation, described as:
• “Locked in exhalation”
• “Exhalation restriction”
•”Limited in inhalation”
•”Depressed”
What is an inhalation dysfunction?
A rib that fails to move fully into exhalation, described as:
• “Locked in inhalation”
• “Inhalation restriction”
• “Limited in exhalation”
• “Elevated”
What should you assess when evaluating rib dysfunction?
• Quality of rib movement (hypomobility, pain on springing)
• Function during inhalation and exhalation
• Sequential and bilateral rib movement
What are general red flags for ribcage-related conditions that require emergency medical attention?
• Severe ribcage pain
• Chest pain
• Crushing feeling or pressure in the chest
• Severe shortness of breath
• Difficulty breathing
• Change in consciousness
Why should the thoracic spine always be considered in assessment and treatment?
The thorax is a site for global and intrinsic muscle attachments (shoulder & pelvic girdles, cervical spine), affecting posture, stability, and function.
What aspects should be considered during assessment and treatment of the thoracic spine and rib cage?
• Standing posture and core stability
• Limb movement, load bearing, and gait
• ADLs, postural habits, and work-related postures
• Breathing patterns and their effect on musculature
• Psychological factors (stress, anxiety, PTSD, trauma)
• Rule out red flags (systemic disease, infection, fractures, cancer, nerve lesions)
• Use the “Rule of 3” for palpation and landmarking
Why should adaptive shortening or contracture not be fully corrected before addressing bony misalignment?
If functional leg length discrepancy (LLD) exists, correction must occur first. If structural, the patient will need a shoe lift or referral.
What should be done after correcting bony misalignment?
• Treat adaptive shortening/lengthening
• Improve postural awareness
• Progress slowly and communicate potential symptom changes
What are some self-care strategies for patients with thoracic spine or rib dysfunctions?
• Postural awareness in daily activities
• Stretching for short-tight muscles
• Strengthening long-tight muscles (especially endurance for postural muscles)
• Spinal mobility exercises (cat-cow, flexion, extension, side-bending, rotation)
• Breath awareness and retraining
• Core exercises (spinal stability, multifidi retraining)
• Proprioception and balance exercises
• Strength-length balance in agonist-antagonist relationships
• Referral to movement therapies (physiotherapy, yoga, tai chi, Feldenkrais, dance)
