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PTRS 845 > Thoracic spine > Flashcards

Thoracic spine Flashcards

1
Q

What is the prevalence of thoracic spine pain?

A

Spinal pain in general population: 66%
LBP: 56%
Neck- 44%
Thoracic- 15%

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2
Q

What are the rule of 3 with thoracic surface anatomy?

A

SP of T1-3 @ same level as TP
SP of T4-6 @ 1/2 level below level of TP
SP of T7-9 @ 1 level below level of TP
SP of T10-12 @ same level of TP

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3
Q

What is osseous anatomy of TS?

A

Highest vertebrae share commonalities with CS
Lowest vertebrae share commonalities with LS
Thoracic vertebrae A/P and transverse dimensions of the vertebral bodies are a uniform ratio
Height is slightly higher posteriorly

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4
Q

What are orientation of facet joints in TS?

A

Joints are synovial and planar.
Primarily oriented in frontal plane
Superior articulation: 60 degrees above horizontal and 20 degrees from the frontal plane laterally
Inferior articulation: match superior and face anterior, inferior, and slightly medially

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5
Q

What are the disc ratios in the body?

A

CS: 2:5 (28.5%)
TS: 1:5 (16.6%)
LS: 1:3 (25%)

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6
Q

What are attachments of ribs 1 and 2?

A

1: no superior portion of CVJ, attaches to sternum under SC joint
2: CVJ with demifacets above and below, attaches anterior at sternomanubrial junction

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7
Q

What are attachments of ribs 3-7?

A

Typical posterior attachment, direct attachment to sternum anteriorly

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8
Q

What are attachments of ribs 8-10?

A

Typical posterior attachment, attach to sternum via costocartilage of 7th rib anteriorly

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9
Q

What are attachments of ribs 11-12?

A

no articulation with superior vertebra, no CTJ, no anterior articulation

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10
Q

What is neurological supply of thoracic spine?

A

Each thoracic spinal nerve divided into anterior and posterior primary rami exiting below its respective vertebra.
Anterior rami travels along each relative nerve and becomes the intercostal nerve (supplies internal/external intercostals and serratus posterior)

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11
Q

What is posterior rami divided into?

A

Divided into medial and lateral branches

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12
Q

What does lateral branch of posterior rami nerve supply?

A

longissimus, iliocostalis, costotransverse joints

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13
Q

What does medial branch of posterior rami nerve supply?

A

upper 6 levels: semispinalis, multifidus, skin of upper back
Lower 6 levels: transversospinalis, longissimus
Every level: facet joints above and below that level

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14
Q

What are sinuvertebral nerves in TS?

A

small nerves that branch from the spinal nerve near the origin of the anterior and posterior rami and then re-enter the intervertebral foramen

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15
Q

What does sinuvertebral nerve supply?

A

PLL, proximal ribs and outer fibers of disc, venous plexus, post vertebral bodies, anterior aspect of laminae, the dura
Has spinal root and sympathetic root

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16
Q

What is path of sympathetic chain in TS?

A

lies anteriorly along rib heads and costovertebral joints

Thoracic dysfunctions may lead to sympathetic and visceral symptoms

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17
Q

What is the critical zone in the TS?

A

Spinal canal is more narrow in the mid thoracic spine (T4-T9).
Decreased blood supply (only one blood vessel, anterior spinal artery, supplies this area)
Disc herniation/injury can lead to central spinal cord compression here causing tension along the path of a nerve
T6= tension point (positive slump)
Treat with mobilization and manipulation

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18
Q

What are the thoracic pain and referral patterns?

A

Facet joints- 1/2 segment superior to 2.5 segments distal and slightly lateral
Clowards areas: cervical disc dysfunction will radiate to medial scapular border and T spine
60% incidence of osteophyte encroachment of costovertebral on sympathetic chain

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19
Q

Where is pain with dissecting thoracic aneurysm, CAD, Peptic ulcer?

A

Aneurysm: sudden chest pain radiating to back that’s unrelenting, emergency
CAD: anterior chest pain, has CPR
Ulcer: boring pain to mid T-spine after eating

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20
Q

What is CPR of CAD?

A 
Age (>65 for females, >55 for males)
Known for vascular disease
Pain worse during exercise
Not reproduced with palpation
Patient feels that it is cardiac in nature
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21
Q

What are serious conditions associated with thoracic pain?

A

Cancer historical information (history of cancer, age over 50, failure of conservative therapy, unexplained weight loss)
Ankylosing spondylosis (chest expansion 30 minutes, improvement of back pain with exercise but not with rest, awakening because of back pain during second 1/2 of the night only, alternating buttock pain)
Fever for infection

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22
Q

What happens during flexion/extension of TS?

A 
Superior vertebral body translates anteriorly and rotation anteriorly in sagittal plane.
Posterior rib translates superiorly
Anterior rib translates inferiorly
Anterior rotation of rib
Reverses for extension
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23
Q

What happens when TS rotates?

A

Greatest in upper segments and reduced in lower
Coupled SB: ipsilateral in upper TS, opposite in lower
Ipsilateral rib translates inferiorly and rotates posteriorly
Contralateral rib translates superior and rotates anteriorly

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24
Q

What happens when TS side bends?

A

Most limited in upper segments and increases in lower segments
Ipsilateral rib moves inferiorly and rotates posteriorly
Contralateral rib moves superiorly and rotates anteriorly
Ipsilateral facet joint extends and glides inferolaterally
Contralateral facet joint flexes and glides anteromedially

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25
What is thoracic spine and rib movement during respiration?
Sagittal view: pump handle movement (ribs 1-6) Frontal view: bucket handle (ribs 7-10) Transverse view: caliper movement (ribs 11-12)
26
What are coupled movements in TS?
``` Cervicothoracic region (C7-T1, T1-T2): SB and rot occurs on same side Thoracolumbar region (T11-12, T12-L1): SB and rot occurs on opposite side Mid TS region: variable coupling of SB and rot T2-7: extend, rotation and SB to ipsilateral side with full elevation of arm ```
27
What are neurodynamic problems with TS?
Sympathetic chain is tensioned during flexion, contralateral rotation, contralateral SB @T6 in slump position the cord is tensioned cranially toward C-spine and caudally toward L-spine T4 syndrome- stiffness @ T4 causing HA, neck pain, UE pain, bilateral stocking glove paresthesias
28
What are pathomechanics of TS ?
Flexion movement impairment: most often in upper TS, relative reduction of kyphosis, rear impact injury, can be unilateral Extension movement impairment: more common in CT junction and highest segments, excessive kyphosis posture, if advanced age and chronic vertebral bodies may become wedge shaped
29
What are rib pathomechanics?
Superior subluxation: first rib, limit painful caudal glide, progress to thoracic outlet if bad enough Anterior subluxation: traumatic blow to posterior chest wall, may be able to palpate prominence of rib anteriorly or concavity posteriorly Posterior subluxation: anterior chest wall trauma, most treatments are mobilization or manipulation
30
For objective assessment of TS what is part of your postural assessment?
Hips- level greater trochanters, asymmetry of hips in frontal or transverse plane Pelvis- pelvic obliquity, A/P rotation of pelvis, SLS L-spine- curvature in sagittal plane, mm tone, tenderness to palpation T-spine- scapular positioning, curvature in sagittal/frontal plane, looking at each region independently, verticality of spine (acromion in line with GT), shoulder height C-spine- forward head posture, asymmetry in C-spine tone, vertical neck
31
What are parts of motion analysis in TS assessment?
``` Standing tri-planar movement of trunk- lumbopelvic rhythm, symmetrical rotation/SB, inclinometer measurements, combined movements, single leg stance Seated thoracic spine active movement Scapulohumeral rhythm Cervical motion analysis Gait analysis ```
32
What is part of palpation assessment in TS?
muscle tone of paraspinals/trigger points PPAVM and PPIVM- central PA/unilateral PA/rib screws First rib mobilization assessment Cervical traction/compression Rib expansion assessment in seat position Skin mobility- gliding and rolling in various directions
33
What is part of strength assessment in TS?
``` Seated in "collar up" position Prone trunk extension endurance test Cervical/lumbar flexor endurance test Resisted rib expansion testing Scapular stabilizer MMT ```
34
What is the number 1 thoracic spine problem mark sees in the clinic?
Thoracic pain associated with something else
35
Who gets thoracic vertebral fractures and how?
Often associated with osteoporosis or impact injuries | Most frequent in 5th decade and afterward
36
What are objective findings for vertebral fractures?
Tends to be in kyphotic position | Extension activities may help reduce stress on vertebral body and increase blood flow to area
37
What is treatment for vertebral fractures?
Safely restoring function while preserving integrity of healing Surgical vertebroplasty is option but research shows it's no better than sham
38
What is functional scoliosis?
Lateral curvature w/o rotational component | Curvature can be corrected by changing patient position
39
what causes functional scoliosis?
Can be lead to by mm spasm, inflammatory conditions, injuries, hamstring injury, nerve root
40
How do you treat functional scoliosis?
Treat underlying cause and the scoliosis will resolve | Stretch concave side, strengthen convex
41
What is structural scoliosis?
Lateral curvature with rotational component Does not change with position Vertebral bodies can become wedge shaped in frontal plane
42
What is cause of structural scoliosis?
Congenital, secondary to a neurological disorder, or idopathic
43
What is treatment of structural scoliosis?
Curves irreversible | Work on managing symptoms
44
What are treatment ideas for scoliosis?
``` Stretch shortened high tone concave side Strengthening stretched out convex side Postural correction training Bracing Surgical intervention ```
45
What is the thoracic outlet?
space between clavicle and first rib | subclavian artery and brachial plexus
46
What causes thoracic outlet syndrome?
Due to elevated or abnormal first rib after a traumatic injury or overuse of repetitive overhead activities
47
What are symptoms of thoracic outlet syndrome?
Nerve symptoms Blood vessel symptoms Difficulty with overhead activities
48
What are nerve symptoms of thoracic outlet syndrome?
vague aching pain in neck, shoulder, arm, or hand May also cause pain, numbness, or tingling on inside of forearm and the 4th/5th fingers of hand especially with shoulder elevation. Weakness may make hands clumsy
49
What are blood vessel symptoms of thoracic outlet syndrome?
reduced blood flow resulting in swelling and redness of your arm and hands May feel cool and easily fatigued
50
What is treatment of thoracic outlet syndrome?
first rib mobs, scalene stretch, pec stretch, soft tissue mobs, strengthening mid and lower traps
51
What is cause of flattened upper thoracic spine
increasd tension in the nervous system; stiff surrounding joints; natural posture history of MVA and whiplash
52
What are signs of flattened upper thoracic spine?
Stiffness of CTJ and mid thoracic (T3-7) Flexion restriction May lead to constant loading of joints and mid back pain
53
What is treatment for flattened upper thoracic spine?
Unload joints, improve mobility, scapular and thoracic stability
54
Who gets generalized upper/mid thoracic stiffness?
Middle or older aged person
55
What is cause of generalized upper/mid thoracic stiffness?
prolonged acquired posture, natural posture, metabolic changes
56
What are objective findings of generalized upper/id thoracic stiffness?
generalized stiffness at multiple levels, loss of elastic end-feel, limited arm elevation, stiff and painful accessory glides, muscle imbalance
57
What is treatment for generalized upper/mid thoracic stiffness?
mobilization, flexibility, strengthening, posture education, breathing techniuqes
58
Can thoracic spine have referred pain?
can refer pain and paresthesia to th ehead, upper limbs, and hands
59
What does sympathetic nervous system have to do with thoracic spine and referred pain?
sympathetic outflow to head is supplied by T1-4 and upper limb is supplied by T2-5 Due to sympathetic ganglion, the SNS could be pathway for referral from the thoracic spine to upper limb
60
What are subjective findings for T4 syndrome?
parasthesis, altered and extreme temperature perception and puffiness in the glove distribution of both hands intermittent posterior thoracic pain or pain around the scapula region
61
What are aggravating and relieving factors of T4 syndrome?
symptoms worse last thing at night or with activities involving thoracic flexion/slumping Position of comfort tends to be laying completely flat
62
What are postural objective findings for T4 syndrome?
Increased cervical lordosis and cervico-thoracic kyphosis | Flattened and restricted upper thoracic spine (T2-7)
63
What are findings with palpation for T4 syndrome?
Local tenderness and symptoms reproduced with mobilization of spine anywhere between levels T2-7 (historically T4)
64
What are mobility findings of T4 syndrome?
Minimal thoracic movement during single arm elevation to either side Local hypomobility of vertebral segment associated with symptoms
65
What are nerve objective findings for T4 syndrome?
Positive ULTT | Positive slump test
66
What is treatment for T4 syndrome?
``` Central or unilateral PA soft tissue work rib mobility mobility exercises posture training ```
67
What are symptoms and aggravating factors for costal joint derangement?
Pain with breathing, trunk rotation, unilateral PA over CTJ, pain and stiffness with rib mobility Aggravated by twisting or reaching
68
What is costal joint derangement?
reduced costal mobility-->rotation
69
What is treatment for costal joint derangement?
limit trunk rotation in acute stage, rib mobilize and exercise in chronic stage, soft tissue work
70
What are causes of elevated first rib?
chronic neck pain | poor posture
71
What is the rib vulnerable too?
vulnerable to superior movement due to lack of superior supporting ligament at the costotransverse joint Scalenes attach to ribs 1 and 2
72
What are symptoms for elevated first rib?
trapezius spasm, neck pain, headaches, shoulder pain, radiculopathy, jaw pain, mid back pain, chest and sternal pain. TOS End range cervical rotation limits and shoulder elevation
73
How do you test the first rib?
stabilize first rib rotate head to contralateral side side bend to ipsilateral side positive sign: pain at rib, decreased ROM, firm end feel
74
What are symptoms of rib subluxation?
localized pain, reduced motion during inspiration/expiration, coughing and sneezing; local muscle spasms
75
What is treatment for rib subluxation?
rib mobilization/manipulation, MET, posture training, soft tissue work
76
What are signs of anterior or posteriorly subluxed rib?
anterior: concavity of rib posteriorly Posterior: prominence of rib posteriorly
77
What are signs and symptoms of thoracic disc lesions?
Pain may be isolated to upper back or radiate in dermatomal pattern Pain shooting around or through chest wall Possible sensory deficits (numbness/tingling below herniated level, neurological weakness in LEs)
78
What are aggravating factors of thoracic disc lesions?
any movements, deep breathing, cough/sneeze
79
What are causes of thoracic disc lesions?
Acute- forceful rotation injury Chronic- degenerative changes Most occur in lower TS levels about 15% of population
80
What are objective findings of thoracic disc lesions?
``` local muscle spasms +PA +AROM +UMN/LMN +/- slump +Beevor's sign (T10-12) ```
81
What is treatment for thoracic disc lesions?
traction, mobilization, breathing exercises, position and posture exercise, cervical and/or lumbar core strengthening
82
What is Tietze's syndrome?
Chostochondritis- localized irritation of costosternal joint (2nd rib) Includes swelling of costal cartilages (costochondral junction)
83
What are causes of Tietze's syndrome?
rib lesion, inflammation, viral infection, repetitive movement
84
What are symptoms of Tietze's syndrome?
Anterior chest pain, localized and superficial, worse with breathing and trunk movement hypomobility of TS Pain and swelling over joint
85
What are treatment for Tietze's syndrome?
Usually resolves in 12 weeks | Treat posterior lesion, RICE, ice, anti-inflammatories
86
What is ankylosing spondylitis?
Systemic rheumatic disease causing inflammation of spine. | Gradual onset, progressive stiffness-fusion of joints
87
Where does ankylosing spondylitis occur?
starts in SI and migrates up spine | young people
88
What are symptoms of ankylosing spondylitis?
pain, limited chest excursion, limited spinal mobility, X-ray, +bone scan
89
What is treatment for ankylosing spondylitis?
mobility exercise and active life style
90
What is cause of osteoporosis?
female, body size, use of steroids, lack of nutrition, and exercise
91
How does osteoporosis affect TS?
wedging and increased kyphosis, compression fracture of TL vertebrae and ribs
92
What are symptoms of osteoporosis?
symptomless, increase kyphosis and overall loss of height, x-ray, bone scan
93
What are symptoms of compression fracture?
Pain with movement, breathing and palpation
94
What is treatment for osteoporosis?
weight bearing exercise, muscle strengthening, dietary advice
95
What is pathology of osteoporosis?
Fish vertebrae: biconcave appearance of vertebra, indicates osteopenia
96
What is Scheuermann's disease?
Wedging of multiple vertebral bodies.
97
What happens when someone has Scheuermann's disease?
Vertebra grow unevenly in sagittal plane Deformity progresses until skeletal maturity is reached More likely to suffer from thoracic disc herniation
98
What are Schmoral's nodes?
small herniation of disc material into the endplate of vertebral bodies
99
What can nodes lead too?
Juvenile arthritic kyphoscoliosis/vertebral osteochondrosis | Premature disc degneration
100
What are symptoms of scheuermann's disease and schorals nodes?
pain and stiffness | rigid curved spine
101
What are treatments for scheuermann's disease and schorals nodes?
exercise to improve mobility and back care bracing surgical intervention
102
What are general suggested treatments for thoracic spine hypomobility conditions??
mobilization/manipulation of appropriate segments and joints followed by appropriate HEP
103
What are general suggested treatments for thoracic spine muscular conditions??
stretching and strengthening, patient education, etc
104
What are general suggested treatments for thoracic spine posture conditions?
address posture and work situation, HEP
105
What are general suggested treatments for thoracic spine hypermobility conditions??
stabilization (strengthening), patient education, check mobility of other joints, treat possible hypomobile segments
106
How do you mobilize ribs?
Joint line of costotransverse and costovertebral joints are in general anterior-medial Mobilize perpendicular to joint line- anterolateral Stabilize contralateral side to prevent rotation

PTRS 845 (9 decks)

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