Thoracic Spine

Question 1

What percent of population with spinal pain reports thoracic/lumbar/cervical pain?

Answer 1

15% thoracic
56% lumbar
44% cervical

Question 2

Which spinous process is in line with inferior angle of scapula?

Answer 2

Conventionally: T7.

More recent study: Most often at T8, can vary from T4-T11

Question 3

Rule of 3s for spinous process alignment in t spine

Answer 3

T1-3: Spinous process at level of transverse process
T4-6: Spinous process 1/2 vertebral level below transverse process
T7-9: Spinous process full vertebral level below transverse process
T10-12: Spinous process at level of transverse process

Question 4

Description of vertebra size/shape in t spine

Answer 4

• Vertebral bodies become larger and denser from superior to inferior
• Taller posteriorly > kyphosis
• Thoracic discs are thinner than cervical and lumbar

Question 5

Review anatomy of rib articulation with vertebrae

Answer 5

Ribs 3-9 are “typical” > 2 facets (inferior and superior)
Ribs 1, 10-12 only have 1 facet

Costotrasnsverse joints are concave/convex from T1-T6, planar from T7-T12 > pump handle upper, bucket handle lower with inspiration. Other studies have shown rib cage motion is similar at all levels.
11th/12th ribs move in caliper-type motion b/c no anterior attachment or costotransverse joint.

Question 6

Spinal extensor weakness and reduced muscle density has been associated with:

Answer 6

Thoracic hyperkyphosis, osteoporosis, decreased QOL, increased risk of falling in older adults

Question 7

Neurovascular review

Answer 7

• Each thoracic spinal nerve exits below its disk
• Each thoracic spinal nerve contributes preganglionic sympathetic fibers to sympathetic chain
• Subcostal nerve (T12th spinal nerve) irritation at thoracolumbar junction could lead to referred pain in the hip region.
• There is potential for upper thoracic spine to refer to UEs.

Question 8

“Critical zone”

Answer 8

T4-9> Smallest spinal canal diameter, reduced blood supply. Significant pathology here could cause central spinal cord compression.

Mobility impairments here can > neurogenic and sympathetic signs (T4 syndrome)

Question 9

Thoracic spine joint referral

Answer 9

Zygapophyseal joints:
- C5-T1: paravertebral region, inferior to parascapular region
- T3-T11: Usually right around or slightly below level affected
Costovertebral joints: Pain directly over joint. Osteophytes here can > pseudovisceral pain due to proximity to sympathetic chain.

Patients with more chronic pain usually have less localized sxs

Question 10

ROM of t spine based on region

Answer 10

• Flexion/extension: Increases from T1 to T12 as facets become more oriented in sagittal plane.
• Sidebending: Increases from T1- T12. Controversy as to whether thoracic rotation couples contralaterally or ipsilaterally during sidebending.
• Rotation: Higher in upper segments. Average = 26 deg.

Question 11

S/s of T4 syndrome

Answer 11

HA, neck pain, UE pain, bilateral stocking glove paresthesia.

Question 12

Thoracic flexion mobility impairment

Answer 12

Typically occurs in middle t spine, T3-7

Thought to occur after whiplash-type injury as a result of rear-impact collision

Question 13

Thoracic extension mobility impairment

Answer 13

Typically occurs in upper thoracic/CTJ region and lower thoracic spine.

Common in older adults, associated with decreased QOL and increased risk of falling.

Can be improved with exercise programs.

Question 14

Clinic prediction rule to rule our CAD in primary care

Answer 14

In patients >35 yo and reporting anterior chest pain:

1. Male >54, female> 64
2. Known clinical vascular disease
3. pain worse during exercise
4. pain not reproducible with palpation
5. patient assumes pain is of cardiac origin

^Presence of 3 = 87% Sn, 80% Sp

Question 15

Murphy sign

Answer 15

For cholecystitis

Pain with deep inspiration while palpating the right subcostal region

Question 16

Renal colic

Answer 16

Pain in flank accompanied by lower abdominal pain that spreads into labia/ testicles

Question 17

Pts at risk for kidney infection

Answer 17

Hx or current UTI

Question 18

Primary cancers most likely to metastasize to t spine

Answer 18

Breast
Lung
Colon

Question 19

Greatest shift in probability of cancer is with ____history/subjective finding

Answer 19

Hx of cancer

Question 20

Clinical prediction rule to identify ankylosing spondylitis

Answer 20

1. Morning stiffness >30 min
2. Improvement in back pain with ex but not rest
3. Awakening with back pain during second half of night only
4. Alternating buttock pain.

94% Sp if 3 positive

Question 21

Key physical examination implicating ankylosing spondylitis

Answer 21

Limited chest expansion
Normal: 5cm measured at nipple
Limited: <2.5 cm

HLA-B27 has high false positive rate

Question 22

Infection in t-spine

Answer 22

Not common

Red flags include: Fever, chills, night sweats, recent infection, current IV therapy or drug use, recent surgery.

Question 23

Risk factors for osteoporosis

Answer 23

Caucasian
Hx of smoking
Early menopause
Thin body build
Sedentary lifestyle
Steroid treatment
Excessive consumption of caffeine or alcohol

Risk:
Gradually increases for men
Sharply increases after 65 for women

Question 24

Vertebroplasty for compression fracture

Answer 24

No benefit over passage of time.

Question 25

Imaging for t-spine

Answer 25

• Acute pain with risk for osteoporotic fx: Xray
• Suspected CA or infection: MRI, bone scan
• Trauma: No imaging unless they have spinal tenderness, neurological signs, or altered consciousness.

Question 26

Lifestyle factors potentially associated with tspine pain

Answer 26

Tobacco use, alcohol use, lack of PA, work related stress, family issues.

Question 27

Association between posture and pain

Answer 27

No relationship except in most severe postural abnormalities.
Should use symptom modification procedure to identify whether posture is relevant to patient’s pain.

Question 28

Measuring thoracic kyphosis

Answer 28

Inclinometer at T1-2 and T12-L1, Sum the two angles.

Kyperkyphosis = Cobb angle > 50 deg

Question 29

Identifying C7

Answer 29

Doesn’t move with cervical flexion.

Question 30

Thoracic segmental mobility testing

Answer 30

Better when assessment is based on regions rather than a specific segment.

Question 31

Potential risk factors for poor recovery

Answer 31

Depression
Fear of movement
Pain catastrophizing

Life stressors, substance abuse, poor sleep

Question 32

Manipulation: General vs. specific

Answer 32

Equal results. Manipulation likely produces forces to a region of the spine as opposed to only at the targeted segment.

Question 33

Contraindications to seated thoracic manipulations

Answer 33

Shoulder discomfort in position
History of anterior shoulder instability
Therapist can’t reach arms around the patient

Question 34

Purpose of lower trap training in tspine pain

Answer 34

Improve or maintain extension in middle-lower thoracic region
Facilitate normal scapular-thoracic motion

Manip to mid-lower t spine can facilitate lower trap firing

Question 35

Prone thoracic extensor strengthening

Answer 35

Decreased incidence of vertebral fracture in 10-year follow up

Question 36

Manual therapy to t spine for pts with cspine or shoulder pain

Answer 36

Typically beneficial.

Unlikely that shoulder kinematics will be affected, but pain often benefits pain.